CE: Making a Great Impression by Dr. Leif Stromberg

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Simplified accurate edentulous impressions and other records for enhancing complete denture success

by Dr. Leif Stromberg

Keys to Success and Predictability With Fabrication of Complete Dentures

PART 1 (April): The consultation/examination appointment
PART 2 (this month): Simplified techniques for final impressions
PART 3: Simplified techniques for accurate records
PART 4: The wax try-in appointment
PART 5: Delivery of successful complete dentures

Abstract
Achieving consistent success in creating tissue-supported complete dentures demands a systematic approach. A pivotal step in this process is impression-making. This course focuses on fundamental and simplified techniques for obtaining accurate final impressions, and the importance of creating additional records during the impressions appointment to elevate the overall success of complete denture fabrication.

The course focuses on aspects of impression-making, including the choice of materials, with a particular focus on the efficacy of alginate. Specific instructions are provided for using heavy-body and light-body alginate materials, combined with a syringe delivery system, to ensure accurate complete denture impressions. The significance of maxillary denture posterior extension, including the vibrating line and hamular notches, is emphasized for retention and patient comfort.

Patient cooperation and comfort during the impression-making process are discussed. The course also highlights the value of patient engagement, encouraging them to provide photos and discuss preferences for the fabrication of dentures that are aesthetically pleasing to the patient.

Furthermore, the course outlines efficient laboratory preparations, including using tools like the Swissedent wax rim former and contouring wax rims based on specific measurements provided by the dentist. Adequate laboratory preparations are important for streamlining the records appointment and enhancing the accuracy and ease of recording.

Learning objectives
After completing this course, readers should be able to:

Implement the simplified impression technique to make accurate impressions for tissue-supported complete dentures.
Create records for streamlining the records appointment and enhancing the success of the denture fabrication process.
Increase patient engagement and discuss how this contributes to creating personalized and predictable prostheses.
Communicate effectively with dental laboratory technicians, further elevating the efficacy and success of complete denture construction.

Introduction
Predictably fabricating successful tissue-supported complete dentures requires a meticulous and systematic approach to ensure fit, comfort, stability, retention and aesthetics. One of the crucial steps in this process is making accurate impressions, which significantly influences the final prostheses’ outcome. Shortcomings in this step can lead to postdelivery issues, causing frustration for both dental professionals and patients.

This course focuses on fundamentals and simplified methods for accurate final impressions for tissue-supported complete dentures. It also emphasizes the importance of creating additional records during the impressions appointment to enhance the success of the final dentures.

Course topics

Simplified final impression techniques for tissue-supported complete dentures: A streamlined approach for achieving accurate impressions.
Additional records made during the impressions appointment.
Adequate laboratory preparations: Preparing for the records appointment to enhance accuracy and efficiency.

The simplified final impression technique
Patient assessment: Before beginning the process, assessing the patient’s stomatognathic condition is important to increase denture outcome predictability. Identifying unstable elements within the stomatognathic system that are subject to changes that could negatively affect the final complete dentures is crucial. This evaluation typically occurs during the consultation/ examination appointment.

Select and modify the impression tray: Select an appropriate-sized edentulous impression tray that matches the patient’s arch form and size. Ensure the tray provides optimal coverage for all structures to be impressed and for supporting the impression material. Modify the tray, if necessary, to accurately reflect the patient’s anatomy. Thermoplastic impression trays, such as AccuDent XD and Massad edentulous impression trays, can be easily modified by placing the tray in hot water and reshaping them. Follow directions for the trays being used.

Record the essential structures in edentulous impressions: For maxillary impressions, record the entire alveolar ridge, tuberosities, hamular notches, posterior palatal seal area, vibrating line, hard palate and vestibules to muscle function (Fig. 1). For mandibular impressions, record the entire alveolar ridge, buccal shelves, retromolar pads, labial and buccal vestibules to muscle function, and alveololingual sulcus (Fig. 2).

Fig. 1

Fig. 2

Select impression materials: The presented simplified edentulous impression technique employs alginate impression material because of its accuracy, cost-effectiveness and ease of use. Using two alginate materials of different viscosities (tray and syringe materials) and a syringe delivery system helps achieve excellent edentulous impressions. For example, the author recommends the AccuDent XD Impression System by Ivoclar.

Use tray material that is heavy body, high viscosity, and does not run down the patient’s throat. Use syringe material that is light body, low viscosity, and non-slumping; this way, the syringe material stays where injected and can be border-molded.

It is recommended to always use the appropriate adhesive on the impression tray when making an alginate impression to ensure the retention of the impression material to the tray. Follow the adhesive product directions.

Mark the posterior extensions of the maxillary and mandibular dentures: Intraorally locating and marking the posterior extensions of the maxillary and mandibular dentures offers several advantages. It is much easier to accurately find the denture extensions in the mouth than on a master cast. Also, having these borders located and marked helps ensure the final impressions include these important landmarks. Using indelible ink (Fig. 3) to mark these extensions on the tissues allows for precise transfer to the master casts, aiding the laboratory in contouring the denture base properly for maximum denture retention and patient comfort.

Fig. 3

Maxillary denture posterior extension: To enhance maxillary denture retention and increase the predictability of denture success, the dentist should indicate on the master cast the posterior border of the denture at the vibrating line and the hamular notches. This enables the lab to create an accurately placed posterior denture border and a post dam on the maxillary denture (a raised area on the tissue side along the posterior border of the maxillary denture), which compresses the tissues of the posterior palatal seal area and the hamular notches and improves retention of the denture.

Locate the hamular notches: Firmly place a dental mirror against the maxillary alveolar ridge crest and slide the mirror posteriorly across the tissues of the ridge and the tuberosity into the compressible tissues of the hamular notch, which is distal to the tuberosity (Fig. 4). Then, mark the hamular notch with indelible ink to indicate the posterior extension of the maxillary denture in the hamular notch area.

Fig. 4

Locate the vibrating line: The posterior extension of the maxillary denture between the hamular notches should be located at the vibrating line, which is the junction of the movable and the immovable soft palates (Fig. 5). To locate the vibrating line, instruct the patient to make “ah-ah-ah-ah” sounds and observe the movable soft palate move up and down. The junction of the movable and immovable soft palates, the vibrating line, can be seen and marked.

Fig. 5

Sometimes, the movable soft palate moves minimally, making finding the junction challenging. It is recommended to use magnification when locating and marking the vibrating line intraorally. The fovea palatinae—indentations near the midline of the palate formed by a coalescence of several mucous gland ducts—can be used as a guide for the location of the vibrating line (Fig. 6). They are always present in the soft palate (posterior to the hard palate) and are usually but not always anterior to the vibrating line.

Fig. 6

The nose-blowing technique can also be used as a guide to locate the vibrating line. The patient’s nose is held closed, the patient blows their nose with their mouth open, and the movable soft palate moves down (Fig. 7). When using this technique, some of the immovable soft palatal tissues are displaced, so this does not accurately show the location of the vibrating line; this shows the clinician approximately where the vibrating line is, and the patient can next repeat the “ah-ah-ah-ah” sounds so the vibrating line can be detected and marked.

Fig. 7

Note the maxillary denture posterior extension on the master cast: The denture base should extend posteriorly to the vibrating line and the hamular notches. The dentist should mark these landmarks on the master cast to accurately show this denture’s posterior extension to the lab. The lab technician should use this information to create a post dam on the maxillary denture, creating a seal across the posterior of the maxillary denture.

Mandibular denture posterior extension: The posterior extension of the mandibular denture should rest on the retromolar pads, which are primary support areas for the mandibular denture. The retromolar pads are palpable, soft, compressible, nonkeratinized tissue at the posterior end of the mandibular alveolar ridges. After the loss of the molars, the bony ridges remodel and usually resorb. The pads are important landmarks for the posterior extension of the denture and the occlusal plane level of the denture teeth. The denture should cover two-thirds of the pads, with the posterior denture extension in the upper one-third of the pads.

To locate the retromolar pads, run a finger along the alveolar ridge and feel the pad at the distal end of the residual ridge. The pads can be marked with indelible ink, and the impression tray can be tried into the mouth to verify that the posterior extensions of the tray will cover the pads so the impression will accurately record them.

Impression technique for the edentulous maxilla: Mix light-body alginate impression material and place in a syringe; mix heavy-body impression material and place in an impression tray. Inject the syringe material into the hamular notches and vestibules (Fig. 8), ensuring these areas are recorded in the impression. Seat the tray (Fig. 9) and ensure the borders of the impression are border-molded.

Fig. 8

Fig. 9

Border molding of the maxillary impression simulates muscle function and replicates the shape and size of the vestibules. This is accomplished by manipulating the lip and cheek muscles adjacent to the final denture borders. Pull straight down on the vermilion border of the upper lip at the philtrum (Fig. 10). Massage the cheeks lightly with the fingers (Fig. 11). When border-molding, be careful not to move the impression tray, which would distort the impression.

Fig. 10

Fig. 11

Impression technique for the edentulous mandible: The mandibular denture should rest on the retromolar pads, so the pads must be located intraorally, marked (Fig. 12) and included in the mandibular impression. If the laboratory knows the location of the retromolar pads, it can make the posterior extensions of the mandibular denture rest on them. Inject the light-body alginate material into the buccal, labial and lingual vestibules (Fig. 13). Seat the tray, ensuring the retromolar pads are incorporated in the impression (Fig. 14).

Fig. 12

Fig. 13

Fig. 14

Help the patient be at ease: Patient cooperation is vital during the impression-making process for accurate impressions. Communicate the procedure to the patient, address their concerns and make them comfortable to minimize anxiety and facilitate a successful impression. Let them know how they can help, such as by remaining still and letting the tongue relax on the floor of the mouth for the maxillary impression and holding the tongue up when making the mandibular impression.

Evaluate the impressions: Assess the final impressions for accuracy, detail and completeness. Remake if necessary.

Additional records made during the impressions appointment
In addition to impressions, several other records should be made to enhance the complete denture fabrication. These records include:

A preliminary (not final) verticentric record, a simultaneous recording of the vertical dimension of occlusion and centric relation.
Papillameter, alameter and alma gauge measurements. These measurements guide the initial contours of the maxillary aesthetic wax rim, enabling them to be close to the final wax rim contours so minimal chair time will be necessary for adjustments.
Instructions to the laboratory regarding the initial contours of the maxillary aesthetic wax rim and setup instructions for the recording device for the verticentric record. Include the vertical length of the central incisor area of the wax rim below the incisive papilla, and the horizontal distance that the incisal edges of the central incisor area of the wax rim should be labial to the center of the incisive papilla.

Directions for registering a preliminary verticentric record
This initial verticentric record is intended for laboratory use when setting up the verticentric recording device, usually a gothic arch tracer or wax occlusal rims. Its purpose is to assist the laboratory in setting up the final verticentric recording device closely with the final recording, minimizing the need for significant chairside adjustments during the records appointment.

Select an appropriate tray for the preliminary verticentric record, such as an Ivoclar Centric Tray (Fig. 15) or a full-arch disposable bite registration tray (Fig. 16). For this record, use a fast-setting putty (Figs. 17 and 18).
Determine the preliminary vertical dimension of occlusion for the patient. Mark reference points on the tip of the nose and the most anterior median point of the chin (Fig. 19).
Instruct the patient to lick their lips, swallow and relax their lower jaw. The mandible comes to a rest position with the lips touching when the mandibular elevator muscles are in minimal contractual activity. Measure the distance between the reference points, representing the vertical dimension of rest. Make a note of this measurement. Calculate the preliminary vertical dimension of occlusion by subtracting 3 mm from the vertical dimension of rest measurement. This derived measurement is often close to the final vertical dimension of occlusion, which will be accurately determined during the records appointment for the patient.
Next, load the selected tray with a fast-setting putty or heavy-body vinyl polysiloxane impression material (Fig. 20).
Insert the tray in the patient’s mouth (Fig. 21) and guide the patient to close their jaws to the preliminary vertical dimension of occlusion measurement. Guide the patient to close in centric relation (Fig. 22). You can say, “Close slowly, focusing on your back teeth.”

Fig. 15

Fig. 16

Fig. 17

Fig. 18

Fig. 19

Fig. 20

Fig. 21

Fig. 22

Using the alma gauge
The alma gauge is designed to determine the horizontal and vertical relationships between the incisal edges of the maxillary central incisors and the incisive papilla. It serves as a way of effectively communicating these measurements to the dental laboratory. These measurements can play a crucial role in guiding the initial contours of the maxillary wax rim so it closely matches the patient’s existing dentures. Additionally, these measurements can be customized based on the patient’s anatomical features and preferences, allowing the laboratory to construct the wax rim according to altered dimensions determined by the dentist (Fig. 23).

Procedure: The patient’s old denture is positioned on the table of the alma gauge. The plunger of the gauge is lowered into the center of the incisive papilla (Fig. 24). The measurement grid on the plunger indicates the distance the incisal edges of the central incisors are vertically below the incisive papilla; the horizontal measurement grid on the table of the alma gauge shows how far horizontally the incisal edges of the central incisors are positioned labially to the center of the incisive papilla.

The laboratory can use these measurements to contour the central incisor area of the wax rim to match the dimensions of the patient’s existing denture (Fig. 25). Further refinements of the wax rim will be made during the records appointment to determine the final positions of the incisal edges of the central incisors. Also, the dentist can customize the measurements. For example, the vertical length can be increased, making the wax rim vertically longer (so more teeth will show) than the patient’s existing central incisors on their denture. The dentist could instruct the laboratory to construct the central incisor area of the wax rim longer by a specific amount, such as 2 mm longer than the teeth on the existing denture.

Fig. 23

Fig. 24

Fig. 25

Using the alameter
The tips of the alameter are used to measure the widest part of the nose, which is the distance from one ala of the nose to the contralateral ala (Fig. 26). The alameter reading is a guide to the width of the maxillary dental arch at the canines. The reading indicates the approximate width of the maxillary wax rim at the canine locations and the width of the six maxillary anterior teeth from the center of one canine to the center of the contralateral canine. The measurement also serves as a guide for selecting the mold for the anterior denture teeth.

Fig. 26

Using the papillameter
The papillameter is designed to measure the length of the patient’s upper lip in relation to the incisive papilla when the lip is in a relaxed state. This measurement provides a reference for the length of the lip below the incisive papilla and is used by the dental laboratory technician in establishing the anterior length of the wax rim according to the patient’s anatomical features and preferences. This, in turn, helps determine the position of the anterior teeth.

There is a flat platform on the back of the papillameter (the opposite side to the measurement grid, Fig. 27). The papillameter is positioned under the upper lip, the flat platform is placed against the incisive papilla, and the length of the relaxed upper lip can be measured on the grid (Fig. 28). The amount of lip movement can be assessed by measuring the lip length in full smile and comparing it with the relaxed lip length.

Fig. 27

Fig. 28

Communicate specific instructions about rim contours to the laboratory: It is important to request the aesthetic wax rim with a specific vertical length and, specifically, how far labial to the incisive papilla the incisal edge of the wax rim in the central incisor area should be. Rather than providing vague instructions like “construct wax rim,” the dentist should give precise guidance.

Benefits of delegating to the laboratory: Delegating the task of contouring the wax rim to the laboratory with clear instructions can significantly reduce chairside time. This time saved during clinical appointments can then be devoted to refining the wax rim contours to more accurately represent the positions of the denture teeth.

Other guidelines for contours of the anterior portion of the wax rim: The length of the anterior portion of the wax rim and the horizontal distance from the center of the incisive papilla to the incisal edges of the central incisors can often be determined from the patient’s old denture. This can be measured with the alma gauge and communicated to the laboratory. If the dentist wants the denture teeth to be set in a different relation to the ridge than found on the old denture, measurements can be given to the lab as vertically longer or a specific horizontal position. If the patient’s old dentures are unacceptable or have been lost, the wax rim and the teeth can be set in relation to the upper lip; the papillameter measurement will help with this. Also, other guidelines are available for tooth position.

Another helpful measurement that can guide the wax rim length is to have the incisal edge location of the maxillary lateral incisor area of the wax rim 20–22 mm below the peripheral border of the denture in that area (Fig. 29). This is often very aesthetic and close to the patient’s natural teeth locations.

Fig. 29

At the consultation/examination appointment, these measurements and guidelines can also be used to evaluate the patient’s old denture to determine if a new denture can have teeth set to more aesthetic positions and match the patient’s desires and expectations.

Ensure retention and stability of the maxillary baseplate with the wax rim: When evaluating and contouring the wax rim, it is important that the baseplate remains securely in place intraorally. This ensures the patient can comfortably and naturally move their mouth, smile and speak without the baseplate becoming dislodged from the maxillary ridge. Request the dental laboratory to create a well-fitting retentive maxillary baseplate. Additionally, consider the option of digital fabrication using 3D printing or milling to achieve an optimal fit and retention.

Request patient engagement: Encourage patients to bring photos of themselves showing their natural teeth while smiling before tooth extractions. This provides a visual reference for restoring their natural appearance and positioning the denture teeth as close as practical to the estimated position of the patient’s natural teeth. Additionally, ask patients to share pictures from magazines or online of smiles they admire and would like for themselves; this allows for a deeper understanding of their aesthetic preferences, guiding the design of dentures that align with the patient’s vision and desires for their new smile.

Laboratory preparations for the records appointment
Based on the records and instructions gathered during the impressions appointment, effective laboratory preparations play a vital role in optimizing the clinical records appointment and ensuring increased record accuracy.

The laboratory should diligently follow the dentist’s instructions regarding the initial wax rim contours to minimize the need for chairside adjustments. this results in greater efficiency and accuracy during the final records appointment. The baseplate with the wax rim should also closely conform to the master cast for good intraoral retention, but there should not be a post dam on the baseplate.
Using the Swissedent Wax Rim Former (Fig. 30) will create the maxillary wax rim with an occlusal plane parallel to the horizon (and to the interpupillary line) and parallel antero-posteriorly to the ala-tragus line. The heated wax rim former is rotated upward against the wax rim, and the wax rim can be melted down to the desired length (Fig. 31).
The laboratory should use the alameter measurement as a guide for the width of the anterior sextant of the wax rim.
The papillameter measurement can be used as a guide for the length of the wax rim in the central incisor area. As another option, the dentist may indicate a preference for using the former denture as the guide and give measurements using the alma gauge for contouring the wax rim. With the laboratory following these measurements, refining the wax rim’s contours during the records appointment can be streamlined.
Use the preliminary verticentric record as a valuable guide for setting up the gothic arch tracer or wax rims in very close alignment with the final verticentric record.

Fig. 30

Fig. 31

Conclusion
Mastering techniques for making accurate final impressions, along with obtaining additional records and measurements as discussed in this course, significantly improves the predictability and success of tissue-supported complete denture treatments. Achieving this success requires each step to be done competently by all members of the dental team, active collaboration with the patient, effective communication with the laboratory, and the judicious use of appropriate materials and techniques. These combined efforts play a pivotal role in consistently delivering successful dentures that satisfy the patient, function well, and contribute to the patient’s overall well-being.

As the field continues to evolve with the introduction of new materials, techniques, and advancements in digital technology and dental implants, maintaining a strong foundation in these fundamental principles empowers dentists to assess their potential for enhancing workflow and creating higher-quality restorations more efficiently. This adaptability ensures that dental professionals can stay at the forefront of delivering excellent patient care in an evolving dental landscape.

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Dr. Leif Stromberg has also created a five-part series of video CE courses for Dentaltown about keys to success when creating complete dentures. Click here to check out the lineup.

Author Bio

Leif Stromberg, DDS, MAGD, FADI, FICD, practices restorative dentistry in Dallas. Stromberg was selected as a Texas Super Dentist in Texas Monthly magazine from 2005 to 2017. In 2022, he became a Texas Academy of General Dentistry Dentist of the Year Award nominee, and in 2023 he earned fellowship in the International College of Dentists.

Stromberg, who also served as a clinical assistant professor at Texas A&M University College of Dentistry from 2000 to 2005, is frequently solicited to present at dental conferences on techniques for predictably successful complete dentures and has written a textbook on the same topic. Website: strombergdentistry.com

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Simplified accurate edentulous impressions and other records for enhancing complete denture success

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CE: Making a Great Impression by Dr. Leif Stromberg

Simplified accurate edentulous impressions and other records for enhancing complete denture success

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