|Year : 2020 | Volume
| Issue : 1 | Page : 55-59
Prosthodontic management of hypermobile ridge using modified window impression technique and liquid-supported denture
Siddharth Mehta1, M Mohammed Ziauddeen2, Pulkit Chandra3, B Rohith4, Abha Mehta5
1 Department of Prosthodontics, Bapuji Dental College and Hospital, Davangere, Karnataka, India
2 Department of Prosthodontics, College of Dentistry, Majmaah University, Az-zulfi, Saudi Arabia
3 Private Practictioners, Consultant Prosthodontist and Implantologist, Jaipur, Rajhasthan, India
4 Private Practictioners, Consultant Prosthodontist and Implantologist, Bangalore, Karnataka, India
5 Department of Periodontics and Implantology, Bapuji Dental College and Hospital, Davangere, Karnataka, India
|Date of Submission||19-Feb-2019|
|Date of Acceptance||03-Dec-2019|
|Date of Web Publication||16-Jul-2020|
Dr. Siddharth Mehta
Door No 5389, Behind Nutan College, LIC Colony, Davangere - 577 004, Karnataka
Source of Support: None, Conflict of Interest: None
Abused, inflamed, atrophic, and flabby ridges always pose a great challenge to a prosthodontist in the fabrication of complete dentures. Healthy underlying tissue is a prerequisite for a successful denture. In flabby ridges, due to the compressible nature of the tissues, the denture might lose stability very soon. Liquid-supported dentures may act as a viable option which provides a soft, resilient, and adaptable intaglio surface of the denture. It helps in the preservation of the residual ridge resorption by optimal distribution of the masticatory forces and gives adequate retention, stability, and support. This article describes a case report of prosthodontic management of a flabby ridge nonsurgically, with a modified window impression technique and a liquid supported maxillary denture for better patient acceptance and comfort.
Keywords: Flabby ridge, hypermobile ridge, liquid-supported denture, window impression technique
|How to cite this article:|
Mehta S, Ziauddeen M M, Chandra P, Rohith B, Mehta A. Prosthodontic management of hypermobile ridge using modified window impression technique and liquid-supported denture. Int J Oral Health Sci 2020;10:55-9
|How to cite this URL:|
Mehta S, Ziauddeen M M, Chandra P, Rohith B, Mehta A. Prosthodontic management of hypermobile ridge using modified window impression technique and liquid-supported denture. Int J Oral Health Sci [serial online] 2020 [cited 2021 Jan 18];10:55-9. Available from: https://www.ijohsjournal.org/text.asp?2020/10/1/55/289882
| Introduction|| |
Flabby ridge is a hypermobile and extremely resilient tissue formed due to the replacement of the bone by fibrous tissue due to the excessive load on the ridge and unstable occlusal conditions. The reported prevalence has varied but has been demonstrated in up to 24% of edentulous maxillae and 5% edentulous mandibles. As the flabby tissues are easily distorted while impression making steps, the dentures fabricated on such foundations are often compromised in its retention and stability. Several treatment modalities offered in such patients include surgical excision of flabby mass, implant-supported dentures, or conventional prosthesis without surgery.,
Impression making plays a critical role in complete denture fabrication. A particular problem is encountered if a flabby ridge is present within an otherwise “normal” denture-bearing area. An impression technique is required which will compress the nonflabby tissues to obtain optimal support and at the same time will not displace the flabby tissues. Several techniques such as the Hobkirk technique, Zafarullah Khan technique, Liddlelow technique, Osborne technique, and McGregor technique have been described in the literature for the careful recording of the flabby tissue.,,
Liquid-supported denture is a novel and innovative technique which allow continued adaptation of the denture base to the mucosa in the resting and functional state. This design acts as a continuous reline for the denture, improves the retention, and allows uniform distribution of masticatory load. This article presents a case report where a flabby ridge is managed nonsurgically with modified impression technique and a liquid-supported maxillary denture for better patient acceptance and comfort.
| Case Report|| |
A 58-year-old patient reported to the Department of Prosthodontics, Bapuji Dental College and Hospital, Davangere, Karnataka, India, for the replacement of his existing worn out maxillary and mandibular complete dentures. Clinical examination revealed moderately resorbed maxillary and mandibular arches with a flabby ridge in the maxillary anterior region [Figure 1]. Furthermore, the maxillary denture-bearing area was inflamed and was tender on palpation in the maxillary anterior ridge region. The inter-arch distance was adequate, and the ridge relation was Class I. The existing dentures were used for the past 9 years, and the occlusal surface of the teeth was attrited and an obvious reduced vertical dimension was noted. Fabrication of a liquid-supported maxillary complete denture with a conventional mandibular denture was planned for this patient.
After a thorough intraoral examination, mucostatic impressions of the maxillary and mandibular arches were made with Alginate irreversible hydrocolloid material (Zelgan Plus, Dentsply, India). Border molding was then done using a greenstick compound (Pinnacle tracing sticks, DPI, India) using the sectional method. After the border molding, a window was prepared in the custom tray in the maxillary anterior region corresponding to the flabby ridge. A final impression with zinc oxide–eugenol impression paste (DPI Impression paste, DPI, India) was made of the remaining tissue surface. The tray was then left in the mouth and impression plaster (Snow White Plaster #2, Rapid set, Kerr, USA) was mixed into slurry and was applied over the flabby tissue area exposed through the prepared window. Once the impression was set, the tray was retrieved from the mouth and was inspected for any voids or any deficiencies [Figure 2]. The jaw relation procedure, try-in procedure, flasking, and dewaxing procedures were done in a conventional manner.
|Figure 2: Maxillary final impression made using window technique with Zoe and impression plaster. The mandibular final impression made with Zoe|
Click here to view
Next, a 0.5-mm thick thermoplastic vacuform sheet (Easy-Vac gasket, 3A MEDES, Korea) was adapted on the maxillary cast. The vacuform sheet was then cut 4-mm short of the sulcus and also 2-mm short of the anterior vibrating line [Figure 3]. PVS putty (Express XT Putty Soft, 3M ESPE, USA) was then mixed and kept between two glass plates and was pressed till a 0.5-mm thin sheet was formed between the glass plates. This sheet of putty was then adapted over the vacuform sheet before the putty was set. The set putty was then cut 1 mm short of the vacuform sheet all over [Figure 4]. The dewaxed molds along with vacuform and putty spacer were packed with heat cure acrylic (Trevalon Denture material, DPI, India) and acrylization was done in a conventional manner.
|Figure 4: A 0.5-mm putty spacer created and placed over the adapted vacuform sheet during denture packing|
Click here to view
After the finishing and polishing of the processed dentures, the vacuform sheet from the intaglio surface of the maxillary denture was teased open from the posterior palatal seal area and the putty spacer was removed [Figure 5]. This ensured a space of 0.5 mm between the vacuform sheet and acrylic of the denture for the intervening liquid. The vacuform sheet was then sealed back to the denture with the help of a medical-grade cyanoacrylate-based adhesive (Marvilyte, Maritz Pharmaceuticals, Bengaluru, India) [Figure 6] and [Figure 7]. A hole was drilled on the cameo surface of the denture which acted as a channel for the infusion of the liquid into the prepared space [Figure 8]. Glycerin (Nice Chemicals, Kochi, India) was injected into the space through the hole [Figure 9] and [Figure 10], and the hole was sealed with self-cure acrylic. The purpose of glycerin is to act as a shock absorber and distribute the forces acting on the denture uniformly to the underlying denture-bearing area [Figure 11]. The dentures were inserted and checked for occlusion, phonetics, and esthetics. The patient was instructed regarding the postinsertion care of the dentures.
|Figure 5:Vacuform sheet teased off and putty spacer removed after the denture acrylization|
Click here to view
|Figure 6: Medical-grade cyanoacrylate adhesive used to seal the vacuform sheet back to the denture|
Click here to view
|Figure 8: Hole created on the cameo surface of the denture to act as a channel for liquid infusion|
Click here to view
|Figure 11: Intaglio surface of the processed denture with liquid interspersed in between|
Click here to view
| Discussion|| |
Surgical removal of flabby tissues may not always be feasible. Removing the shock-absorbing flabby ridge may lead to trauma of the underlying bone (with the patient feeling soreness) and increased bulk of denture material. There is also the risk that the flabby ridge may recur. The removal of the fibrous material may also reduce the height of the ridge decreasing the chances of a stable denture. Modifying the impression technique to record the flabby tissue in a mucostatic manner and remaining tissues in a mucodisplacive manner will definitely be more advantageous and a more practical approach.
Hobkirk described a technique to use a custom tray with a double spacer in the region of the flabby ridge and making final impression with light-body elastomeric impression material. Khan et al. described a technique of using a custom tray with a window in the region of flabby ridge and making a mucostatic impression of the flabby ridge by painting impression plaster through the window. In 1964, Osborne described a technique where two separate impression trays and materials were used to separately record the “flabby” and “normal” tissues and then related intraorally. Watt and McGregor in 1986 described a technique where impression compound was applied to a modified custom tray and a wash impression with zinc oxide and eugenol was made.
An ideal denture should continuously adapt to the mucosa, be able to withstand masticatory forces, and have flexible tissue surface to reduce stress concentration and trauma on the underlying tissues. At the same time, it should be rigid enough to support the teeth during function. Heat-cure acrylic denture base resins do not completely satisfy these above-mentioned properties, owing to which other softer and more resilient materials such as soft liners and tissue conditioners were introduced. All these materials are temporary because they lose their resiliency over a period of time and also encourage candidal growth, thus requiring several relining visits and follow-ups. Liquid-supported denture is, therefore, an agreeable option which is more permanent, more economical, and also provides better adaptation of the denture base to the mucosa.
A study conducted by Nitin HC et al. utilized strategically placed strain gauges which could measure strain accurately when simulated masticatory load was applied through a universal testing machine. Considerable reduction in the strain values were observed with the liquid-supported denture when compared to conventional dentures and this was favorable for the tissues.
The intervening liquid should have a viscosity which ensures the desired inertia of the movement and thus improve stability. In the present case, glycerin was used as an intervening liquid, which is a colorless, odorless liquid with good thermal stability, water repellency, low surface tension, biocompatibility, low vapor pressure, and low cost. Singh et al., used olive oil as an intervening fluid claiming to have all the physical properties of glycerin and poses no harm to the patient if ingested, as it is edible.
The adhesive used is Iso-Amyl 2 cyanoacrylate which is used in surgery as an alternative to suturing and as a protective covering over ulcers, etc., Keni et al., Dammani et al., and Singh et al. used a similar technique for sealing the vacuform sheet to the denture base using medical-grade cyanoacrylate adhesive.
| Conclusion|| |
Flabby ridges, due to their increased resiliency and compressibility, may cause a basic hindrance in obtaining stability to the denture. Surgical removal of the hypermobile tissue or implant-supported overdentures although may seem to be more sensible option in such cases may not be practical and economical. A nonsurgical prosthodontic approach of recording the hypermobile tissue in their mucostatic form and providing a liquid-supported denture will ensure a constant contact of the intaglio surface of the denture with the mucosa, thereby increasing the stability of the dentures along with uniform force distribution on the denture-bearing area, resulting in better patient comfort and acceptance.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to b'e reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Crawford RW, Walmsley AD. A review of prosthodontic management of fibrous ridges. Br Dent J 2005;199:715-9.
Bansal R, Kumar M, Garg R, Saini R, Kaushala S. Prosthodontic rehabilitation of patient with flabby ridges with different impression techniques. Indian J Dent 2014;5:110-3. [Full text]
Lynch CD, Allen PF. Management of the flabby ridge: Using contemporary materials to solve an old problem. Br Dent J 2006;200:258-61.
Hobkirk JA. Complete Denturesda Dental Practitioner Hand Book. Bristol: Wright; 1986. p. 44-5.
Khan Z, Jaggers JH, Shay JS. Impressions of unsupported movable tissues. J Am Dent Assoc 1981;103:590-2.
Keni NN, Aras MA, Chitre V. Management of flabby ridges using liquid supported denture: A case report. J Adv Prosthodont 2011;3:43-6.
Dammani B, Shingote S, Athavale S, Kakade D. Liquid-supported denture: A gentle option. J Indian Prosthodont Soc 2007;7:35-9. [Full text]
Nitin HC, Nair CK, Shetty J, Sadhvi KV. Comparative evaluation on stress distribution pattern of conventional and liquid-supported dentures: An in-vitro
study. Trends Prosthodont Dent Implantol 2013;4:27-9.
Singh E, Shetty S, Jnanadev KR, Manjula N, Norton KP. Fabrication of modified liquid supported complete denture using olive oil. Int J Curr Res 2018;10:66463-6.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]