Teaching an abbreviated impression technique for complete dentures in an undergraduate dental curriculum

Jacqueline P. Duncan, DMD, MDSc,a and Thomas D. Taylor, DDS, MSDb School of Dental Medicine, University of Connecticut, Farmington, Conn. Statement of problem. Traditional methods for teaching complete denture fabrication are timeconsuming, difficult to master, and not used by many general practitioners.

Purpose. This study compared the efficacy of traditional denture fabrication techniques with a more
abbreviated method in a dental school setting. Material and methods. A retrospective record review of 80 completely edentulous patients treated by predoctoral dental students was completed. Forty patients were treated with traditional denture techniques; the other 40 patients were treated with an abbreviated method. The data abstracted included the number of visits to completion and the number of postinsertion visits and relines required within the first 3 months after delivery. A Wilcoxon rank sum test was performed to determine statistical significance between the groups with regard to number of visits for fabrication and postinsertion adjustments. A test for a difference in proportions by using the normal approximation to the binomial distribution was performed for statistical analysis of the incidence of relines. Results. The abbreviated denture technique resulted in a statistically significant difference in the number of visits for fabrication (P<.01) and postinsertion adjustments (P<.05.) There was no difference (P=.39) in the number of relines between the 2 groups. Conclusion. Teaching the abbreviated complete denture technique in an undergraduate dental clinic decreased the number of appointments necessary to complete denture therapy without increasing the number of adjustments or reline procedures. (J Prosthet Dent 2001;85:121-5.)

CLINICAL IMPLICATIONS
The results of this study support teaching undergraduate dental students an abbreviated impression technique that saves time without substantially compromising the quality of the dentures fabricated.

ost US dental schools teach the fabrication of complete dentures with a final (secondary) impression in a border-molded custom tray.1 Although materials may vary, the principles are similar. Despite the uniformity of training, a substantial percentage of general practitioners appear to abandon what they have been taught and after graduation elect a simpler method for making complete denture impressions.2-4 Until recently, the University of Connecticut taught a selective pressure technique for complete denture final impressions. A custom tray was border molded with modeling compound, and a final impression was made with a low-viscosity condensation silicone impression material. Students then were instructed to fabricate a record base on the master cast by using a light-polymerized resin. Although this method was moderately successful, several difficulties were routinely encountered.
aAssistant bProfessor

Professor, Department of Prosthodontics. and Chairman, Department of Prosthodontics.

First, the process of border molding was a difficult technique to master for students with limited exposure. With a limited number of complete denture patients available, students rarely had the opportunity to become proficient at this procedure. Faculty frequently had to intercede in the process to produce adequate final impressions. Second, the number of visits necessary to obtain an acceptable impression was excessive. Three to 4 visits were routinely needed to complete the examination, treatment plan, and preliminary and final impressions. Third, despite much effort at the border molding and final impression stage, many dentures were found to be overextended at the time of delivery. And fourth, students had difficulty fabricating well-fitting record bases with lightpolymerized resin. Palatal pull away, brittleness and frequent fracture, difficulty in getting baseplate wax to adhere, and the inherent poor wettability of the lightpolymerized materials combined to make their use somewhat problematic.5 Auto-PMMA record bases were not an option because of a decision made by the
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Table I. Comparison between the number of visits required with the traditional denture impression technique (n = 40 patients) and an abbreviated technique (n = 40 patients)
Number of visits to complete denture fabrication* Traditional technique Postinsertion visits during first 3 months after delivery Traditional technique Number of visits to complete denture fabrication* Abbreviated technique Postinsertion visits during first 3 months after delivery Abbreviated technique

6 7 7 7 7 7 7 7 7 7 8 8 8 8 8 8 8 9 9 9 9 9 9 9 9 9 9 9 10 10 10 10 10 10 11 11 11 12 13 14 Mean 8.90 Median 9**

3 1 5 3 3 1 1 4 2 2 1 1 3 2 5 8 1 2 3 2 3 3 3 6 1 3 4 1 7 6 3 3 12 1 3 5 5 2 5 0 3.23 3***

4 4 4 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 8 8 9 9 9 9 11 11 6.5 6**

0 2 2 2 3 2 3 3 2 4 2 2 2 2 1 3 0 4 1 1 0 5 2 2 1 3 4 0 0 1 2 7 2 2 1 2 5 4 1 1 2.15 2***

*Numbers listed do not include postinsertion visits. **Statistically significant P<.0001. ***Statistically significant P<.014.

University of Connecticut concerning the possibility of high levels of monomer released in the student laboratories and potential related health concerns of occupational safety. Because of delays and additional visits needed for denture fabrication, problematic materials being used, and the realization that the average general practitioner is unlikely to use a complicated technique for complete
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denture final impressions, it was decided that the technique taught to dental students would be modified. Students now are taught to make heat-processed acrylic resin denture bases directly on casts obtained from overextended irreversible hydrocolloid impressions made in stock trays. This technique requires a high-quality irreversible hydrocolloid impression with overextension in all areas. Border extensions for the
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denture bases are determined by marking the cast at the point where the alveolar process begins to turn into vestibule. The posterior palatal seal is arbitrarily marked at the fovea palatinae and carved into the cast. The student determines the border extensions with faculty assistance, carves the posterior palatal seal area, and then adapts 2 thicknesses of baseplate wax to the cast, trimming it precisely to the drawn lines. After the pattern is processed, the student places wax occlusion rims and fabricates mounting casts poured into the denture bases modified with appropriate block out. At the second visit, the student and patient are ready for jaw relation records, tooth selection, and mounting of the casts. The first step is to evaluate retention and stability of the processed bases. This task is accomplished with pressure-indicating paste. Tissue adaptation and border extensions are evaluated and adjusted at this stage. This provides the student with an early determination of the stability and retention of the final dentures. If retention or stability is found to be lacking, plans are made to include a laboratory reline at delivery. After maxillomandibular relations and esthetic tryin visits are completed, the teeth are processed to the denture base. It has been documented that secondary processing of the denture base does not cause any significant dimensional changes in the base.6,7 The goals of this technique are to reduce the number of visits and improve the quality of record bases without compromising the quality of the final dentures. The purpose of this retrospective study was to compare the efficacy of the traditional versus abbreviated techniques for fabricating complete dentures in a dental school setting by comparing the following parameters: (1) number of visits needed for denture fabrication, (2) number of postinsertion visits, and (3) frequency of additive corrections (reline) required by the traditional and abbreviated techniques.

Table II. Incidence of relines for the traditional and abbreviated denture impression techniques
Traditional technique Abbreviated technique

Number of maxillary relines* Number of mandibular relines*

5 4

4 2

Not statistically significant P=.39. *Thirteen of the 15 relines were performed at delivery. The remaining 2 (1 from the traditional technique and 1 from the abbreviated technique) were performed within 1 month of delivery.

RESULTS
The number of visits to complete denture fabrication and the number of postinsertion visits are presented in Table I. The total number of relines per group that were required within 3 months after the insertion of the dentures is presented in Table II. The Wilcoxon rank sum test revealed a significant difference between the number of appointments to completion when comparing the traditional and abbreviated techniques (P<.0001). A total of 6 patients did not return for adjustments during the first 3 months after insertion of the dentures. Two statistical analyses were performed for postinsertion appointments. The first analysis included all patients, and the second analysis eliminated those patients who did not return for recall. A significant difference was found in both instances (P<.014 and P<.053, respectively.) No difference (P=.39) was found in the incidence of relines. In addition, there was no difference noted in the timing of the occurrence of relines. A total of 15 relines were needed of the 160 arches treated. Thirteen of these relines were performed on the day of delivery. The remaining 2 relines (1 from the control group and 1 from the study group) were completed within 1 month of delivery of the dentures.

DISCUSSION
The development of an abbreviated technique for complete denture construction that eliminates the use of a border-molded custom tray is certain to elicit concern from those who value more traditional techniques. This retrospective review demonstrated a significant reduction in the number of visits required to fabricate complete dentures without increasing the number of postinsertion appointments or the need for relines. These findings support the validity of this abbreviated technique. There are several advantages to teaching this technique to undergraduate dental students. First, the procedure takes fewer visits, which improves patient morale, compliance, and motivation. Second, the time reduction results in the potential for increased clinical revenue, whether it is in a predoctoral or general practice setting. Border molding is a difficult skill to master
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MATERIAL AND METHODS

The records of 80 arbitrarily selected, completely edentulous patients treated by predoctoral students were reviewed. These patients were divided equally between the traditional technique and abbreviated technique for denture fabrication. The number of visits to completion and the number of postinsertion visits and relines required within the first 3 months after delivery were recorded. A Wilcoxon rank sum test was used to analyze the number of visits and number of postinsertion visits. A test for the difference in proportions by using the normal approximation to the binomial distribution was applied to analyze the statistical significance of the occurrence of relines between the 2 groups. Results were considered significant at the P<.05 level.
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when a students complete denture experience is minimal. Students and practitioners should be comfortable making and recognizing high-quality irreversible hydrocolloid impressions. And third, the need for a clinical remount is virtually eliminated at the time of denture delivery. Mounting casts are made directly into the processed bases. These casts remain mounted on the articulator after centric relation has been verified at the esthetic try-in appointment. After final processing of the denture teeth to the denture base, the laboratory technician is able to place the dentures back on the articulator securely and accurately. The technician and/or student then are able to make final postprocessing adjustments to the occlusion. The apparent reduction in the number of postinsertion visits also appears to be an advantage of this modified technique. However, there are inherent difficulties in using postinsertion visits as a completely valid indicator of denture success. It has been well documented that the success of dentures relies heavily on patient acceptance rather than on the absolute quality of the prosthesis.8-10 This study did not examine patient satisfaction or acceptance of the delivered dentures. In addition, routine postinsertion appointments are to be scheduled for all patients, which require the patient to return at least once during the 3 months after denture delivery. As can be seen in Table I, this did not always occur. Unfortunately, compliance for these appointments can be enforced only within practical limits. One must assume that patients having difficulty will return for adjustments. No change in the incidence of relines between the 2 groups is also a positive indicator of the acceptability of the abbreviated technique. A definite trend was found in the treatment planning of relines. One instructor, of 9 available, was found to have recommended at least a third of the relines performed between the 2 groups. This tendency likely is related to the subjective nature of complete denture evaluation and the personal preference of the instructor. Although this technique has proven to be acceptable in this study, attention to the denture base borders is obviously critical. With the traditional technique, dentures on occasion were returned from the laboratory with knife-edge, overtrimmed borders. This occurred although the vestibule had been border molded and waxed to full contour on the master cast. With the abbreviated technique, there is potential for student error as well as laboratory error. If the thickness of the wax pattern for the denture base is not maintained at the denture bor-

ders, the borders will likely be insufficient. At the University of Connecticut, stricter adherence to detail has been emphasized to faculty, students, and laboratory technicians, and the importance of an effective quality control mechanism has been reiterated. Anecdotally, it has been found that it is better to err on the side of overextension of the initial denture base wax pattern because it is easier to reduce the borders than to add to them.

CONCLUSIONS
The following conclusions can be drawn from this study: 1. A 1-step irreversible hydrocolloid impression in a stock tray, in place of the traditional final impression in a border-molded custom tray, significantly decreased the number of visits required to fabricate complete dentures in a student clinic (6.5 vs 8.9 visits, respectively) (P<.0001). 2. A statistically significant reduction in the number of postinsertion visits required during the first 3 months was demonstrated with the abbreviated impression procedure regardless of whether dropouts were considered in the analysis (P<.014 vs P<.053). 3. There was no significant difference in the occurrence of additive corrections (relines) within 3 months of delivery between the traditional method and the abbreviated method of denture impressions (P=.39).
We thank Dr George Paul for his time and effort as well as Ms Nancy Silliman for her statistical support.

REFERENCES
1. Arbree NS, Fleck S, Askinas SW. The results of a brief survey of complete denture prosthodontic techniques in predoctoral programs in North American dental schools. J Prosthodont 1998;5:219-25. 2. Gauthier G, Williams JE, Zwemer JD. The practice of complete denture prosthodontics by selected dental graduates. J Prosthet Dent 1992;68:308-13. 3. Christensen GJ. An approach to prosthodontics. Meeting the needs of our patients. J Am Dent Assoc 1991;122:64-5. 4. Taylor TD, Matthews AC, Aquilino SA, Logan NS. Prosthodontic survey. Part I: removable prosthodontic laboratory survey. J Prosthet Dent 1984;52:598-601. 5. Boberick KG, McCool J. Dimensional stability of record bases fabricated from light-polymerized composite using two methods. J Prosthet Dent 1998;79:399-403. 6. Brewer AA. Prosthodontic research in progress at the school of aerospace medicine. J Prosthet Dent 1963;13:49-69. 7. Polukoshko KM, Brudvik JS, Nicholls JI, Smith DE. Evaluation of heatcured resin bases following addition of denture teeth using a second heat cure. J Prosthet Dent 1992;7:556-62. 8. Nrhi TO, Ettinger RL, Lam EW. Radiographic findings, ridge resorption, and subjective complaints of complete denture patients. Int J Prosthodont 1997;10:183-9. 9. Diehl RL, Foerster U, Sposetti VJ, Dolan TA. Factors associated with successful denture therapy. J Prosthodont 1996;5:84-90. 10. Carlsson GE, Otterland A, Wennstrm A, Odont D. Patient factors in appreciation of complete dentures. J Prosthet Dent 1967;17:322-8.

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Reprint requests to: DR JACQUELINE P. DUNCAN DEPARTMENT OF PROSTHODONTICS UCONN HEALTH CENTER FARMINGTON, CT 06030-1615 FAX: (860)679-1370 E-MAIL: jduncan@nso2.uchc.edu

Copyright 2001 by The Editorial Council of The Journal of Prosthetic Dentistry. 0022-3913/2001/$35.00 + 0. 10/1/113699

doi:10.1067/mpr.2001.113699

Noteworthy Abstracts of the Current Literature

Fatigue behavior of the zinc-phosphate cement layer Yamashita J, Takakuda K, Shiozawa I, Nagasawa M, Miyairi H. Int J Prosthodont 2000;13:321-6.

Purpose. This study examined the strain responses and ultimate tensile strength of cantilever fixed prostheses cemented onto brass dies with a zinc-phosphate luting agent. Material and methods. Fifty-six 7.6-degreetapered brass dies were manufactured. Twenty-eight had 2 grooves positioned bilaterally, and 28 were manufactured without grooves. Standardized cantilever fixed partial dentures (FPDs) were fabricated for each die with handles at the center of the occlusal surface for tensile testing purposes. The FPDs were composed of 12% Au-Pd-Ag alloy (Castwell MC, GC). Four single element strain gauges were placed onto the marginal portion of each retainer parallel to the long axis of the die. The FPDs were cemented onto each die under finger pressure for 1 minute with zinc-phosphate luting agent (Elite 100, GC). Each cemented specimen was allowed to stabilize for 10 minutes before removal of excess luting agent. All specimens were stored for 24 hours at 37C in a 99% humidity environment. The nongrooved specimens were divided into 3 subgroups. Two of the subgroups comprised 10 specimens each, and the third subgroup comprised 8 specimens. The grooved specimens were similarly divided. With a custom-designed fatigue testing machine, repetitive loads of 50 N were applied to 20 specimens (10 grooved and 10 nongrooved). Total loading cycles equaled 5.5 105. All fatigue tests were completed in 37C water, and testing was completed in 153 hours. Twenty specimens (10 grooved, 10 nongrooved) also were subjected to 100 N loads over the same period with the same total loading cycles. The remaining 16 specimens served as controls and were stored in 37C water for 153 hours. Before repetitive loading began and after every 0.5 105 cycles, strain change was observed as the applied load increased. After fatigue testing, the ultimate tensile strength of each specimen was measured by using a crosshead speed of 0.5 mm/min. A 2-way analysis of variance (=.05) was used to compare tensile strength among the groups. Results. Strain responses were similar at every strain measurement for grooved and nongrooved specimens using the 50-N load. By using the 100-N load during fatigue testing, no difference in strain responses was observed for the grooved specimens; however, strain responses for the nongrooved specimens exhibited differences before and after repetitive loading. No significant differences were observed in ultimate tensile strength among the specimens after fatigue testing. Conclusion. After repetitive loading, no fatigue fracture was observed in the zinc-phosphate luting agent. Stress transmission within the zinc-phosphate luting agent may be improved after repetitive loading.8 References. DL Dixon

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