MAXILLARY IMPRESSION PROCEDURES

INTRODUCTION
The impression procedures are wide and varied

Complete denture impression can be made by considering certain factors

1. Examination and conditioning of the patient and the mouth 2. Selection of the impression material 3. Selection of the impression tray 4. Seating of the patient 5. Selection of the impression procedure 6. Making the preliminary impression 7. Constructing the primary cast 8. Fabricating the custom tray 9. Border molding 10.Making the final impression

1.EXAMINATION AND CONDITIONING OF THE PATIENT AND THE MOUTH

Case history Clinical examination Surgical/non-surgical denture foundation improvement methods Patient education [Steps to reduce gagging, salivation-drug prescription] Assess the anatomical and biological status of denture foundation area

2.SELECTION OF THE IMPRESSION MATERIAL

Preliminary impression materials: Impression compound Alginate

Final impression material: Zinc oxide eugenol Alginate Rubber base Tissue conditioners Impression plaster Impression waxes

3.SELECTION OF THE IMPRESSION TRAY

Stock trays / Custom trays Perforated / Non-perforated
Dentulous / Edentulous

4.SEATING OF THE PATIENT

FOR MAXILLARY IMPRESSION: The patient is seated in an upright position Gravity affects the position of the oral tissues Reclining the chair can cause the material to flow down the palate- gagging/discomfortdisruption of impression Saliva pooling avoided in upright position

OPERATOR POSITION: Stands behind and to the right side of the patient Left hand is brought around from the back of the head to the left side of the patient Left hand for retraction of the lips Right hand to position the tray in the patients mouth

5.SELECTION OF THE IMPRESSION PROCEDURE

Majority of the impression techniques employ variations of the selective pressure theory Factors affecting the choice of techniques are: 1. Clinical findings 2. Experience of the dentist 3. Availability of the material 4. Patient related factors

6.MAKING THE PRELIMINARY IMPRESSION

Common techniques: 1. Border molded custom tray technique usually practiced 2. Border molded compound tray technique 3. Functional impression technique

Border molded custom tray technique

First appnt: preliminary impression in stock tray alginate / impression compound Lab phase: study cast and custom tray Second appnt: border molding and final impression

Why primary and secondary impression?

Difficult to place selective pressure with single unmodified primary impression Border molding and PPS recording will be more accurate

Custom tray can provide a relatively uniform space for the thin impression material

Tray Selection
Select a tray that covers the entire denture bearing area and extends upto the reflection of the mucosa 6mm space between tray and ridge

Posterior extension upto the PPSA

Inserting and centralizing the upper tray

The operator stands on the right side of the patient From behind the patient, the left hand is used to retract the left upper lip and cheek The tray is inserted with the right hand. The right posterior corner is inserted first. The tray is then rotated into position The upper lip is lifted to visualize the tray in relation to the labial frenum It is centered over the ridge so that there is an equal space on all sides of the tray. The labial frenum is used as a guide to align the midline of the tray

 Impression compound softened - hot water bath at 14OF or about 60 to 65C . After kneading - loaded on to the tray - shaped roughly to the shape of the ridge with the fingers. The surface is then warmed and tempered in the water bath The upper lip is retracted - tray centered using the frenum as guide - pressed into position in an upward and backward motion The cheeks and lips are gently finger molded. The tray is stabilized with the finger until the modeling compound hardens sufficiently. After removal it is cooled in chilled water. The impression is inspected for completion

Preliminary Compound Impression

7.CONSTRUCTING THE PRIMARY CAST

Pour the impressions immediately to discard any dimensional instability and to improve accuracy Beading and boxing of the compound impression is preferred to preserve details and periphery of the cast Pour the cast using plaster After set, recover the cast by immersing the whole mass into hot water

 Trim the cast in a wet stone trimmer to attain uniform land area Use a knife to provide uniform sulcus depth of 2-3mm

8.FABRICATING THE CUSTOM TRAY

Marking the cast: the tray extension is marked on the cast with an indelible pencil about 2-3 mm short of the sulcus. Extend tray posteriorly slightly beyond the posterior vibrating line Mark location for wax spacer and relief is provided to the incisive papilla, mid-palatine raphae, undercuts, bony prominence and torus Wax spacer is designed 2mm short of the tray extension

 Acrylic custom trays: apply separating medium and allow to dry Tray fabrication by direct technique, sprinkle on method for acrylic trays, using tray forming molds, vacuum formed trays, light cured trays, shellac trays Trimming the trays: The maxillary tray is trimmed 2-3 mm short of the reflection all around and should extend upto and include the posterior vibrating line. Smoothen and polish the borders

 Handle for the tray is fabricated with a dimension of 8x8x4mm with a 45-60 degree angulation in a position that does not interfere with border molding

9.BORDER MOLDING
Check the tray extension: done segment by segment. Pull lips and cheeks towards the tray and displacement means overextension. Also visually one can check and mark the overextension

 After checking the tray extensions border molding is initiated with a suitable border molding material Definition: The shaping of the border areas of an impression tray by functional or manual manipulation of the tissue adjacent to the borders to duplicate the contour and size of the vestibule

 The muscles which are active when we speak, chew, smile or swallow can have a destabilizing effect on the denture Border molding shapes the impression and allows the muscles to function in harmony

 Materials available: modeling compound sticks, autopolymerizing acrylic resin, elastomers, impression waxes Border molding can be done segmentally or in a single step It can be done by digital manipulation or by functional movements

Maxillary Border Molding

Labial frenum and labial flange : The upper lip is lifted up, then outward, downward and inward. This simulates the movement of the labial frenum Buccal frenum and buccal flange : In the region of the buccal frenum the cheek is pulled upward, then outward, downward, inward and finally forward and backward. This simulates the movement of the buccal frenum Coronoid notch: The activity of the coronoid process is recorded on the distobuccal region by asking the patient to open the mouth wide. The patient is instructed to move the jaw from side to side

 Posterior palatal seal area: has two parts Posterior palatal seal [PPS] and Pterygomaxillary seal [PMS] PMS Behind maxillary tuberosity, in the hamular notch. Located using T- burnisher feel for soft depression beyond the tuberosity PPS Anterior vibrating line [AVL] and Posterior vibrating line [PVL]

AVL cupids bow shape due to projection of posterior nasal spine Junction of hard and soft palate Located by : Valsalva maneuver: hold nostrils firmly and gently blow through nose to position soft palate downwards at its junction with hard palate Or say vigorous ah in short bursts

PVL Junction of the aponeurosis of the tensor veli palatini and the muscular portion of the soft palate Located by asking patient to say ah in a normal, unexaggerated fashion

 Multiple techniques can be employed to record the PPSA: CONVENTIONAL TECHNIQUE FLUID WAX TECHNIQUE ARBITRARY SCRAPING OF THE CAST

 CONVENTIONAL TECHNIQUE: Done after making final impression Master cast is fabricated Shellac trial base fabricated Locate PMS and PVL using indelible pencil Trim upto PVL Locate AVL using indelible pencil Transfer markings to master cast

Scrape area between AVL and PVL to a depth of 1-1.5mm on either side of mid palatine raphae and 0.5 mm depth at the mid palatine raphae and scraping tapers to feather edge as it approaches AVL Check seal in the mouth with mirror after reheating and adapting shellac trial base on the cast

 FLUID WAX TECHNIQUE Recorded after making final impression Locate AVL and PVL in the mouth and transfer to impression surface Molten wax [ Korrecta, Iowa] is painted between two lines Cool and gently press into place for 4-6 mins Flex head - 30 degree downwards

Remove from mouth Good tissue contact glossy appearance and poor contact dull appearance Add wax in deficient area and scrape off from excessive areas Terminate in feather edge near AVL

 ARBITRARY SCRAPING OF THE CAST After fabrication of master cast, scrape off 0.51mm of stone in the PPSA before fabricating the record base.

10. MAKING THE FINAL IMPRESSION

1. Check for retention 2. Prepare and instruct the patient 3. Prepare the tray for final impression: Remove wax spacer Escape holes or vents are provided to reduce hydrostatic pressure build up. Multiple holes at a distance of 5mm is placed in the midline 4. Protect the mouth use petrolactum 5. Dry the mouth

Final impression: equal lengths of base and catalyst paste of ZnOE is mixed to form a smooth uniform mix Load the tray and spread out the material evenly to all parts of the tray Material must be free flowing and not viscous Seat the tray and repeat the border molding movements and allow to set

Remove the impression by breaking the seal by introducing air beneath the dentures Inspect the impression Correct it or remake if needed. Fabricate the master cast using dental stone

FACTORS THAT COMPLICATE IMPRESSION MAKING

Uncooperative patients Gagging Excessive salivation

CONCLUSION
A preliminary impression is made for construction of a custom tray to make the final impression The objective of making an impression should be to record all areas covered by the impression surface of the denture and the adjacent landmarks with an impression material that is accurate and incorporates the minimum of tissue displacement