The document discusses various impression techniques for compromised denture situations including hyperactive gag reflex, restricted mouth opening, flabby ridges, and severely resorbed mandibular ridges. It describes modifications such as using low-flow impression materials, sectional trays, controlled lateral pressure, and the neutral zone technique. Impression making is also modified for some diseases like diabetes by using alternative impression materials and providing space in the denture.

1. IMPRESSION TECHNIQUES IN
COMPROMISED COMPLETE DENTURE
SITUATIONS
GUIDED BY:
DR. U.M. RADKE DR. N.A. PANDE DR. S DESHMUKH
HOD & GUIDE PROFESSOR READER
DR. T.K. MOWADE DR. R. BANERJEE DR. A. CHANDAK
READER READER READER
Presented by:-
Dr. Richa Sahai
I MDS

2. CONTENTS
• Introduction
• Impression techniques for various compromised conditions
1. Hyper active gag reflex
2. Restricted mouth opening
3. Flabby ridges
4. Severely resorbed mandibular ridge
• Modifications in impression making in some diseases
• Conclusion

3. • Before beginning with denture making procedures, a thorough diagnosis of the
patient’s dental condition must be made considering both hard and soft tissues.
This must be correlated with their overall health and their psychological needs.
• The impression procedures must be preceded by detailed history recording,
intraoral examination, diagnostic casts and full mouth radiographs.
Techniques are modified in compromised situations to achieve as much retention
and stability as possible within limits.

4. IMPRESSION TECHNIQUE FOR HYPERACTIVE GAG
REFLEX

5. Dickinson &
Fiske gagging
severity
index (GSI)
1: Normal gagging reflex -
very mild, occasional and
controlled by the patient
2: Mild gagging - Control is
required by the patient
with reassurance from the
dental team
3: Moderate gagging -
Consistent and limits
treatment options.
Gagging prevention
measures are usually
required 4: Severe gagging -
Gagging occurs with all
forms of treatment
including simple visual
examination. Treatment is
limited
5: Very severe gagging -
Affecting patient behavior
and dental attendance and
making treatment
impossible without
specific treatment for
control of gagging.

6. • Borkin (1959) advocated an impression technique for edentulous gaggers by
using impression materials providing minimal flow, greater setting time
• Primary impression is made with modeling compound and secondary
impression was made with KERR impression wax in special tray.
• This low-fusing wax will not set hard at mouth temperature, but it will remain
soft and pliable until it is chilled by the dentist.
• Taking advantage of this characteristic, the tray can be re-seated an unlimited
number of times until the desired results are obtained.
Borkin, D. W.: Impression Technique for Patients That Gag, J. PROS. DENT. 9: 386-387, 1959.

7. • Do not overload the tray.
• Reduction of palatal coverage of maxillary denture:

8. MODIFICATION OF EDENTULOUS MAXILLARY
CUSTOM TRAY TO PREVENT GAGGING:
• The modified maxillary custom acrylic resin tray aids in removal of excess
impression material as it extrudes from the posterior border of the maxillary
custom tray before it can elicit a gag reflex in the patient.

9. a. Retrieve maxillary cast from a preliminary impression in the usual manner
b. Block out all undercuts on the cast and form a tray with autopolymerizing acrylic resin that is 2-3 mm short of all
vestibular extensions. No handle should be placed at this time.
c. Place base plate wax on the superior surface of the tray at the posterior segment. The wax should have roughly
the same outline as the posterior palatal seal, extending from one tuberosity to the other.
d. Attach a disposable saliva ejector to the base plate wax in the midline of the tray. Make sure the tip of the saliva
ejector is embedded in the wax.
e. cover the wax with a thin layer of petroleum jelly.
f. Mix a second batch of autopolymerizing tray acrylic resin. Form this material into a thin sheet and place it over
the wax and tip of the saliva ejector.
The material should extend past the wax and attach to the original tray.

10. g. After the acrylic resin has cured, remove the wax spacer.
h. Smooth any roughness on the tray and polish the tray at this time.
i. Add a wax occlusion rime to the tray to approximate the position and contour of the teeth in the completed
denture.
j. Trim the posterior extent of the tray and border mold in the usual manner.
k. Mix the impression material and load the tray. As the impression tray is being seated in the mouth, the
assistant attaches the low volume evacuation base to the end of the saliva ejector embedded in the tray.
l. Border mold the impression in the usual manner.
m. Remove the tray from the mouth after the impression material extruding from the posterior border of the
tray has been sucked into the vacuum chamber that was formed.

11. Peripherally acting drugs –topical & local anesthetics
Centrally acting drugs – antihistaminic, sedatives , tranquillizers, parasympatholytics
and CNS depressants
Nitrous oxide
PHARMACOLOGICAL TECHNIQUES
Temporal tapping
 Temporal tapping is an ancient Chinese technique used to reduce anxiety and
instill new behaviours.

12. Lift one leg in the air and keep it there.
Ask patient to breath audibly through the nose and at the same time
rhythmically tap the right foot on the floor .
Apnoea – Prolong the expiratory effort at the expense of inspiration.
Reverse counting.
DISTRACTION TECHNIQUES
Bassi G S, Humphris G. M., Longman L. P. The etiology and management of gagging: A review of the literature (J
Prosthet Dent 2004; 91:459-67.)

13. CONTROL OF BREATHING/RELAXATION
• Specific breathing techniques provide the patient with a focus for his/her
attention, giving a feeling of self-control, which, in turn, improves the motivation
to rely on him/ herself to control gagging.
Breathing technique
(National Childbirth
Trust (1958))
controlled, rhythmic
breathing 1–2 weeks prior
to impression taking
Breathing should consist of
inspiration through the
nose and expiration out of
the mouth
Prolonged expiration
should be encouraged
Breathing should be slow,
deep and even
Encouraging
relaxation
advised to imagine scenes
that are calm and relaxing
Muscle tensing, followed by
relaxation of different
muscle groups, such as the
arms and legs can be done
alongside the breathing
technique.

14. THE MARBLE TECHNIQUE
• Five round multi-colored, glass marbles, approximately 1/4inch in diameter.
• The patient is told to put the marbles in his mouth, one at a time, at his leisure,
until all five marbles are in his mouth.
• He is urged to keep the five marbles in his mouth continuously for one week,
except when eating and sleeping.
• Patients with this problem can be treated with as few as two marbles.
Singer, I. L.: The marble technique: methods for treating the hopeless gagger for complete dentures. J. Prosthet.
Dent.29:146, 1973.

15. ACUPRESSURE
• Pressure is placed over certain sensitive points on the body— known as caves—
‘Suan-Zhang’, with the aim to relieve pain, nausea and reactions such as gagging.
• There are several relevant points in relation to gagging:
1. Neikuan or Neiguan cave—anterior surface of the wrist roughly three fingers
breadth from the skin crease of the wrist.

16. 2. Hegu cave—concave area between the thumb and forefinger
3. Chengjiang cave—midway between the lower lip and chin

17. SYSTEMATIC DESENSITIZATION
• Various stimuli may be used, depending on the severity of the gagging problem :
a dental mirror, radiographic film packet, impression trays, a toothbrush,
mouthwash, a spoon or a wooden spatula (Ramsay et al, 1987; Neumann and
McCarthy, 2001).
• The patient is taught how to expose him or herself to the gagging stimulus at
home, and a record of the progress should be kept.
Means CR, Flenniken IE. Gagging-A problem in prosthetic dentistry. J Prosthet Dent 1970;23:614.
Wilks CG, Marks IM. Reducing hypersensitive gagging. Br Dent J 1983;155:263-5.
Wilks CG, Marks IM. Reducing hypersensitive gagging. Br Dent J 1983;155:263-5.

18. DENTAL CHAIRSIDE MANAGEMENT
 Audible breathing
 Flex forehead downwards
 Swallow saliva
 Use of super fast setting impression material
 Trimming of the over extended borders of tray
 Avoid patient visits after meals
 Make patient accustomed to instrumentation
 Use a few drops of lemon juice or salt before impression making.
 Making mandibular impression prior to maxillary one for habituation
 Use minimum amount of impression material

19.  Use 72o or warmer water so the alginate sets faster.
 The dentist must work quickly.
 Seat the tray with alginate in the posterior area first rather firmly so no
alginate will escape in that direction.
 Rotate the front end of the tray up slowly and raise the lip so that alginate
flows toward the anterior and will end in the labial vestibule.
 If some alginate flows past the posterior border, remove it with a quick swipe
of the index finger or a mouth mirror.
 Gaggers often salivate excessively so make sure the head is upright or
slightly forward.
 Use a saliva ejector

20. IMPRESSION TECHNIQUE FOR
RESTRICTED MOUTH OPENING

21. • Patients may exhibit limited opening of the mouth following radical surgery
or a sequel facial burns or due to other pathological conditions.
• Various modifications of the trays can be used, among these are the flexible
trays and the sectional trays used with different modes of reassembling the
segments extraorally after the impression is made.
• The recording of denture borders may be done by either hand manipulation
or functional movement.

22. • Technique I: Flexible impression trays

23. • Technique II: Reinforced flexible impression trays
• This is a modified method of Technique I.
• Here, the flexible impression tray is made of putty silicone material that is
reinforced with an acrylic “U”-shaped device with a cross bar connecting the
two arms.

24. SECTIONAL TRAYS TECHNIQUE
• Technique III: Anteroposteriorly sectioned stock trays

25. • Technique IV: Mediolaterally sectioned stock trays
• Technique V: Technique using magnets

26. Pins and acrylic resin block.
Dowel pins
Hinges
ButtonsDowel pins
& metal wires
Technique VI: Technique using cross pins and slots

27. IMPRESSION TECHNIQUE FOR
FLABBY RIDGES

28. • A flabby ridge is one which becomes displaceable due to fibrous tissue
deposition.
• Most frequently seen in the upper anterior region.
• Usually occurs when natural teeth oppose an edentulous ridge.
• A flabby ridge causes instability of the denture.

29. The main approaches to the management of the flabby ridges are:
• Surgical removal of fibrous tissue
• Injection of sclerosing solution
• Implant retained prosthesis
• Conventional prosthetic management
29

30. 1. SURGICAL REMOVAL OF FIBROUS TISSUE
30
• Advantages
- Firm denture bearing area is produced which enhances
the stability.
• Disadvantages
- Contra indicated if no alveolar bone remains.
- Increase in bulk and weight of the denture base material
- Loss of sulcus depth.

31. 2. INJECTION OF SCLEROSING SOLUTION
• This was suggested by Laskin
• 5% sodium morrhuate
• Supra periosteal injection
31

32. 3. IMPLANT RETAINED PROSTHESIS
Advantages
• Enhanced retention and stability
Disadvantages
• Surgery
• General health of the patient
• Risk of surgical complications or failure
32

33. 1. HOBKIRK TECHNIQUE

35. 2. Zafarullah Khan technique

37. CONTROLLED LATERAL PRESSURE TECHNIQUE
• This technique was given for use with a fibrous (unemployed) posterior
mandibular ridge.
• In this technique, green stick is used to record the denture bearing area
using a correctly extended special tray.
• A heated instrument is then used to remove the greenstick related to the
fibrous crestal tissues and the tray is perforated in this region.
• Light bodied silicone impression material is then syringed onto the buccal
and lingual aspects of the greenstick and the impression gently inserted.
• The excess material is extruded through the perforations and theoretically
the fibrous ridge will assume a resting central position having been
subjected to even lateral pressures.
McCord J F, Grant A A. A clinical guide to complete denture prosthodontics. pp 10-21. London: British Dental Association, 2000

38. IMPRESSION TECHNIQUES FOR SEVERELY
RESORBED MANDIBULAR RIDGE

39. Following are the different impression techniques that
can be used for resorbed mandibular ridges:
• The functional impression technique.
• The admixed technique.
• The neutral zone technique.

40. 1. FUNCTIONAL IMPRESSION TECHNIQUE
• A functional impression can be made after doing the border moulding using a
stable custom tray.
• Temporary soft liners and tissue conditioners can be used as functional
impression materials as they exhibit the property of delayed setting thereby
recording all possible movements of the mandibular musculature.

41. The extensions of the custom tray should be verified accurately and border moulding done.
After completion of the procedure, a functional impression material is used.
The material is mixed and placed on the impression surface of the custom tray.
The material is initially moulded using the regular movements of secondary impression making technique.
Once the material attains an initial set, the patient is instructed to read a news paper aloud, drink water 3-4
times and swallow saliva at regular intervals and other daily chores.
The functional impression material stays within the oral cavity for a period of 45-60 min. All oral activities of
the patient are encouraged.
Once the material has achieved a final set, the tray is removed and the impression is poured.
The cast obtained is used as a master cast for fabrication of prosthesis.

42. 2. ADMIX TECHNIQUE
The philosophy is that :
 A viscous admix of impression compound and
tracing compound removes any soft tissue
folds and smoothens them over the
mandibular bone;
 This reduces the potential for discomfort
arising from the ‘atrophic sandwich’, ie the
creased mucosa lying between the denture
base and the mandibular bone.
McCord J F, Grant A A. A clinical guide to complete denture prosthodontics. pp 10-21. London: British Dental Association, 2000.

43. • Admix of 3 parts by weight of impression compound to 7 parts by weight of
greenstick.
• The admix is created by placing the constituents into hot water and kneading
with vaseline, gloved fingers.
• Using a standard impression technique, the lower impression is recorded. The
working time of this admix is 1–2 minutes and this enables the clinician to
mould the peri-tray tissues to give good peripheral moulding.
• Crestal area cleared of tracing
compound - tray perforated on
crestal area
Definitive impression using
light-bodied polyvinyl siloxane

44. 3. NEUTRAL ZONE IMPRESSION TECHNIQUE.

45. After taking jaw relations, the maxillary and mandibular cast is mounted using a face bow transfer.
Thereafter the mandibular wax rim is cut off and wire loops in the shape of letter "v" are made on the lower record base up to
the height of the mandibular wax rim. (diag.)
Now the maxillary record base is placed in the oral cavity.
Functional impression material is placed within these loops on the lower record base and it is placed within the oral cavity.
The patient is instructed to say words like "ooo", "aaa", and "eee". Pronouncing these words leads to recording of neutral zone
existing in the mouth.
Functional impression is added incrementally at regular intervals in these loops till the time the record base shows adequate
retention within the mouth. (diag.)
Plaster indices are poured around the recorded neutral zones and thereafter, the loops are dismantled from the record base.
After placing these indices, a new occlusal rim is made within the area of plaster indices, which serves as a guide for future
teeth arrangement. (diag.)

47. MODIFICATIONS IN IMPRESSION
MAKING IN SOME DISEASES

48. DIABETES MELLITUS
• In a diabetic patient there is mucosal drying, cracking, burning mouth and
tongue, decreased salivary flow and greater predominance of Candida
albicans.
• So instead of using ZOE for definitive impression some other material like
irreversible hydrocolloids or medium or light bodied elastomeric materials can
be used.
• Healing is impaired in diabetics so a closely adapting denture should be
avoided this can be done by giving a full spacer.
• Use of soft liners should be avoided as much as possible

49. ORAL SUBMUCOUS FIBROSIS
• In this condition patient has minimal mouth opening, the mucosa is atrophied,
submucosal layers are fibrosed which makes the oral mucosa hard and rigid
and imparts bone like consistency.
• For impression making in these patients sectional trays can be used and a
mucostatic material is used for impression making like medium bodied or
irreversible hydrocolloids.

50. SUMMARY
Six fundamental rules for making complete denture
impression by FISHER
• RULE 1: To examine the oral cavity visually digitally and radiographically.
• RULE 2: Surgically removing the abnormalities that can’t be treated
conventionally and those that interfere the successful completion of
impression
53

51. • RULE 3: Obtaining the refined extension of out line for the lower impression.
• RULE 4: To consider the area to be included in the maxillary impression
• RULE 5: To obtain the required retention
• RULE 6: To obtain the required adaptation
54

52. CONCLUSION
• The main objective of impression making is to construct dentures, having
maximum retention and stability, without causing any damage to the
supporting structures.
• Dentists should be able to modify his technique to cope with the conditions
of the basal tissues as presented by each patient.
• Thus, it is the responsibility of the dentist, to select the best possible
procedures, based on sound knowledge, for achieving the best possible
results for the patient.

53. According to Sears, we do not take impressions as we would on a
mannequin; rather ‘we make’ impressions to accommodate the tissues with
their various degrees of displaceability and form.
By knowing a particular patient’s anatomy and tissue tone, the
prosthodontist can select an impression technique to create results that
meet his objectives for retention, stability and patient comfort.
As DeVan said, the ideal impression must be in the mind of the dentist
before it can be in hand..

54. REFERENCES
1. Impressions for complete denture : Bernard Levin
2. Textbook of complete dentures : Charles M Heartwell
3. Prosthodontic treatment for edentulous patients : Zarb bolender
4. Essential of complete denture prosthodontics : Sheldon Winkler
5. Complete denture prosthodontics : John J Sharry
6. Tolman et al. Etiology and management of hypermobile mucosa overlying the
residual alveolar ridge. J Prosthet Dent 1974;32;619-637.
57

55. 7. Izharul Ansari. Establishing the posterior palatal seal during the final
impression stage. J Prosthet Dent 1997;78;324-326.
8. Mc Cord et al. The design and use of special trays in prosthodontics:
guidelines to improve clinical effectiveness. BDJ 1999; 187;423-426.
9. Mc Cord and Grant. Impression making. BDJ 2000;188;484-492
10. Mc Carthy and Ali. The use of pre-border molded custom trays in complete
denture fabrication. J Prosthet Dent 2001;86;655-657.
11. Olivieri et al. A technique for border molding with light polymerized resin. J
Prosthet Dent 2003;90;101-106. 58

56. 12. Kawara et al. Effects of relief space and escape holes on pressure
characteristics of maxillary edentulous impressions. J Prosthet Dent
2004;91;570-576
13. Duncan et al. A selective pressure impression technique for the edentulous
maxilla. J Prosthet Dent 2004;92;299-301
14. Crawford and Walmsley. A review of prosthodontic management of fibrous
ridges. BDJ 2005;199;715-719
15. Lynch and Allen. Management fo the flabby ridge.BDJ 2006;200;258-261.
59