Article-PDF-sheen Juneja Aman Arora Shushant Garg Surbhi-530 (1)

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Indian Journal of Dental Sciences.October 2013 Supplementary IssueIssue:4, Vol.:5

All rights are reserved

www.ijds.inCase Report

of Dental SciencesIndian Journal

E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1

Sheen Juneja2Aman Arora

3Shushant Garg

4Surbhi

Introduction

The highly resorbed residual ridge is thescourge of prosthodontists. Swensonstated, "The ideal ridge is one that is

broad on its bearing surface and has[1]

practically parallel sides". Seldom ares u c h r i d g e s e n c o u n t e r e d b y

prosthodontists. Deterioration of thisideal ridge is frequently encountered,

because of multiple factors, which maybe local or systemic. Stability of lowerdenture in such cases is usually thedistinguishing factor between successand failure.

The natural teeth and ridges or denturesprovide support which is responsible forthe external form of the lips and cheeks.The muscles become weak and do notfunction properly, if the lips and cheeksare unsupported, due to which there will

be wrinkling of skin and sagging of lipsand cheeks . Due t o ag ing , a

prosthodontist has to handle a whole lotof problems like loss of teeth, alveolar

process, tonici ty of musculature,elasticity of skin as well as impairment of

[3]function.

Time to time, dentists have come up withvarious techniques to overcome these

problems in some way or the other .Thisarticle describes a clinical reportwhereby, a customized treatmentapproach was used at every step ofcomplete denture fabrication for a patient

presenting with resorbed ridges, so as toprovide him wi th a successful lyfunctioning prosthesis

099Indian Journal of Dental Sciences. (October 2013 Supplementary Issue, Issue:4, Vol.:5) All rights are reserved.

1 Reader

2 ,3Professor

4 PG Student

Dept. Of Prosthodontics - Dav (C) Dental College

Creating A Denture Using Customized Multi-

Step Approach: A Case Report

Address For Correspondence:Dr. Sheen Juneja AroraReader, Dept. of ProsthodonticsD. A. V. Dental College, YamunanagarPhone no. 0-9996322300Email ID: [email protected]

thSubmission :20 June 2012

rdAccepted :23 August 2013

Quick Response Code

AbstractProviding complete denture therapy to patients with atrophic residual ridge is challenging. Thesepatients frequently suffer ongoing diminution of denture foundation, loss of support of facialmusculature.1 This article presents a multi-step treatment approach, at every step of completedenture fabrication ,which involves physiologically extending the denture bases adequately tocover all of the available supporting tissues,2 followed by using neutral zone technique tomaximize stability of the denture, with special consideration to aesthetics ,by supporting theslumped sunken cheeks with cheek plumpers.3

Key WordsResorbed mandibular ridge, Sunken hollow cheeks, Preliminary functional impression, Neutralzone, Cheek plumpers.

A Case Report

A seventy year old male patient reportedto Department of Prosthodontics atD.A.V (C) Dental College and Hospital,Yamunanagar with chief complaint ofunstable lower complete denture andinability to chew food and was alsoinsisting on improving his aesthetics.History revealed that he was wearing thatdenture since last ten years. Onexamination, it was found that the patienthad highly resorbed mandibular ridge(Class IV) with poor aesthetics,unsupported oral musculature andslumped cheeks. After thorough

evaluation of the patients history,radiographs and existing clinicalconditions, an appropriate and detailedtreatment plan was formulated, keepingin mind all the patients needs anddesires.Since the patient had severely resorbedmandibular ridge, the complete dentureshould be such , that it should cover aslarge area as possible to distributemasticatory forces and at the same time ,itshould not conflict with the adjacentmuscles, which otherwise tend todisplace it. Thus, a primary functionalimpression was made without using tray,so as to have an impression free fromdistortion that stock tray may cause.To overcome the problem of dentureinstability, physiologically appropriateteeth arrangement within neutral zonewas done, so that teeth donot interferewith normal oral and peri-oral muscleactivity .This stabilizes and retains thedenture rather than displacing it.

Special considerations were given foraesthetics to overcome the problem ofsunken cheeks, by supporting them withremovable cheek plumpers. Instead ofconventional cheek plumper as a singleunit prosthesis with extensions on eitherside on the buccal surfaces of the denture,magnet retained plumpers as separate

portions were planned to compensate forthe loss of buccal pad of fat in cheekregion.

Technique1. Impression using metallic core:A 2-mm thick metal wire was adapted to thecurve of the mandibular arch from oneretromolar pad to the other, to serve ascore for impression and a small loop wasincorporated in the anterior part to serveas a handle. To confirm its stability, thewire was seated in the mouth, and the

patient was asked to pronounce certain[4]speech sounds, principally /S/ sounds.(Fig. 1a)

Then the adhesive was applied on thewire and extra heavy-viscosi tyi m p r e s s i o n ( A d d i t i o n V i n y lPolysiloxane, Dentsply) material wasformed into a roll around the wire and the

prepared core was placed in the patient'smouth. After confirming the correct


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swallow, slightly protrude the tongue andlick the lips. Forces exerted mold tissueconditioner into the shape of the neutralzone (Fig.2). These actions wererepeated until material had set. The rimwas removed from the mouth and minordeficiencies were corrected by theaddi t ion or removal of t i ssue

[5]conditioner.

The neutral zone impression was thenreplaced on the master model, locatinggrooves were cut and a silicone puttyindex was prepared around theimpression. The tissue conditionerimpression was then removed fromdenture base and wax was poured intothis space, giving an exact representationof neutral zone. Teeth arrangement wascompleted according to the index andtheir position was checked by placing the

[6]index around the wax try-in (Fig. 3).

3. Try-in and cheek plumpers;After

satisfactory try-in was done, wax rollswere placed in the disto-superior aspectof maxillary buccal flanges. Cheekfullness and vestibular extension wasevaluated and patient approval was takenfor comfort, function and aesthetics.Magnets (cobalt-samarium; MasterMagnetics, Inc., The Magnet Source)were attached to the wax rolls and waxedup (Fig 4). The maxillary and mandibulartrial dentures were waxed up, flasked anddewaxed. The heat cure acrylic resin was

packed by taking care not to dislodge the[7]

magnets.

4. Insertion:During final insertion, thedenture was fully inspected and a checkrecord was made to eliminate any minorocclusal errors. The denture provided the

patient with improved facial appearance,stability and retention during function asthey have been constructed in anatomicand functional harmony with theirsurroundings(Fig.5 & 6).

DiscussionMaking a definitive impression of an

position, the patient was asked to closethe mouth slowly and gently push thetongue forward to touch the lower lips,and the fingers were withdrawn. Patientwas then asked to recite the days of theweek several times slowly and clearly, tofunctionally mould the material bymuscles.Following polymerization, after thestability was obtained, additional

material was added and adapted to thoseregions which were not captured in thefirst impression and molded to createextensions by phonetic molding as doneearlier. After a properly extendedimpression was obtained, its stability andretention was checked and confirmed. Afinal wash impression was made using alow-viscosity silicone material. Thus theimpression was completed in three

phases: main body, extension and surfacewash (Fig. 1b). Then, the maxillaryimpression was made in usual mannerusing impression compound .The

impressions were then boxed, poured andcasts were obtained. Then, custom trayswere constructed on these casts, followed

by border molding and final impressionwith admix technique.

2. Jaw Relation and Neutral Zone:Theimpressions were poured in dental stoneand denture bases were made on themaster casts, over which wax occlusionrims were constructed. The verticaldimension of occlusion was registered byconventional methods and casts werearticulated. The upper occlusion rim wasreturned to the articulator. On lowerrecord base, the wax was removed andsuperstructure was constructed usingauto polymerizing acrylic resin,comprising two pillars in the premolarregion with short vertical fin betweenthem along the centre of denture base.This helped to provide even occlusalstops at the correct vertical dimension ofocclusion and support the neutral zone

[5]impression material .T issue-condi t ioning (Visco-geltemporary soft denture liner, Dentsply)

material was used according to themanufacturers instructions along thedenture base and superstructure to coveracrylic fin and the rim was placed in the

patients mouth along with maxillary waxrim. The patient was instructed to close incentric occlusion as guided by the acrylicshin stops. During this period the patientwas instructed to: smile, grin, pout/purselips, count from 60 to 70, talk aloud,

pronounce the vowels, sip water,

Fig.1 a: Metallic core adapted along the residual ridge b.

Final preliminary functional impression

b

a

Fig. 2 : Recording neutral zone with tissue conditioner

Fig. 3 : Teeth arrangement according to neutral zone index

Fig. 4 : Wax up of the denture with magnets attached to wax

rolls Fig. 5 : Finished prosthesis with magnetic cheek plumpers


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his problems faced in the previousdenture. This article has shown relativelysimple yet effective clinical techniqueswhereby a denture resting on an atrophicmandibular ridge may be modified toimprove function, comfort, appearanceand health to have a successfullyfunctioning prosthesis, complying withthe definition of prosthodontics. All thishave an enormous impact on the patients'

personal lives and are rewarding for theprosthodontist who is providing this

[3]care.

References1. Luthra RP, Gupta R, Vashisht D,

Sharma N, Gupta R: UnemployedResidual Ridge: Indian Journal ofDental Sciences. 2011; (3):4-5.

2. Praveen G., Gupta S., Agarwal S,Agarwal S. K.: Cocktail ImpressionTechnique: A New Approach toAtwoods Order VI MandibularR idge Deformi ty : J I nd i an

Prosthodont Soc 201;11(1):325.3. Sunil Kumar M V, Rao H., Sohi K. S.:

Artificial cheek plumpers: A stepahead in denture aesthetics a casereport. Indian J Stomatol 2011; 2(2):134 7.

4. Aiche H.: A Preliminary functionalimpression for the mandibularcomplete denture: Int J Prosthodont1989:2:543-8.

5. Gahan M. J., Walmsley A.D.: Theneutral zone impression revisited.BDJ 2005;198(5):269-72.

6. Razek M. K. A., Abdalla F.:Two-dimensional study of the neutral zoneat different occlusal vertical heights. JProsthet Dent 1981;46(5): 484-9.

7. Chakravarthy R.: Magnet RetainedSectional Lip Plumper Prosthesis forA P a t i e n t W i t h H e m i -Mandibulectomy: A Clinical Report.Journal of Clinical and DiagnosticResearch. 2010 ;(4):2582-6.

8. McGarry TJ, Nimmo A, Skiba JF,Ahlstrom RH, Smith CR, KoumjianJH. Classification system forcomplete edentulism. The American

College of Prosthodontics. JProsthodont 1999;8:27-39.9. Tautin F.S. Denture aesthetics is more

t h a n t e e t h s e l e c t i o n . J P D1978;40:127-130

10. Martone A. L. Effects of completedenture on facial aesthetics. JProsthet Dent 1964;14:231-5.

to construct a denture that is shaped bymuscle function and is in harmony withthe surrounding oral structures.As the patient ages, the loss of support ofthe facial musculature is of great concernto the patient and carries a great socialstigma. Aging causes tissue atrophy,folds and creases of face becomeexaggerated which is due to loss ofsupport by the alveolar bone and teeth in

particular leading to collapse of lowerthird of face. There is deepening of naso-labial folds, drooping of corner of mouth,loss of vermilion border, depression of

[9]lips with exaggerated wrinkling . Teethloss in posterior region results in loss ofsupport to the cheeks, which tend to movemedially to meet lateral expanding

[10]tongue. Cheek contour changes as aresult of loss of vertical dimension ofocclusion due to anterior teeth loss. Lossof subcutaneous fat and elasticity ofconnective tissue produces the slumped

[3]cheeks.

This clinical report indicated that amagnet retained cheek plumper

prosthesis has potential as a treatmentmethod to alleviate the problems caused

by aging and the resultant loss of muscleactivity associated with such aestheticimpairment. It improves the appearanceof the patient by reducing sagging ofcheeks and improving the muscle toneand has the greatest advantage of

boosting the self esteem of the patient.The advantages of using magnet retained

removable cheek plumpers overconventional are that these are smaller insize, easy to place within dentures, do notcause excessive muscle fatigue and can

be easily removed and cleaned.

Thus, an attempt was made to createdentures that were in harmony anddignity of the aging patient, which wouldcompliment, not eradicate the stigma ofaging in him.

SummaryAs the life expectancy of general Indian

population is increasing, the number ofcomplex complete denture cases is alsoincreasing. So, the treatment of thesecomplex cases needs to move away fromtraditional denture construction to analternative approach to have asatisfactory denture. Thus, a customizedapproach was used for this patient to cater

edentulous arch can be challenging when

the residual ridges present with less-than-ideal conditions, especially when there isminimal bone height, unfavorableresidual ridge morphology and/orunfavorable muscle attachments. Due tothe anatomical differences between themaxilla and the mandible, as well as thedifferences in primary and secondaryload-bearing areas, impressions ofmandibular ridges with resorbed ridge

[8]require special considerations.Mandibular primary impressions ofseverely resorbed edentulous ridges aredifficult to manage well with stock trays.

So a functional impression technique wasused whereby, the impression materialwas formed by the patient's ownmusculature without any distortion fromthe stock tray or the operator's fingers.Such a functional impression gainssupport area that is as large as the activesurrounding muscles permit, without anyconstraint imposed by fingers or borders

[4]of stock trays. Thus , it avoids unduedisplacement of soft tissues andunbalanced extensions and also providesstability with the resulting denture.Moreover, since the patient takes anactive part in the procedure, he feelsrelaxed, comfortable, and confident

because of the stability of the completed[4]

impression.

Next, neutral zone was recorded with anaim to construct a denture in muscle

balance, as muscular control will be themain stabilizing and retentive factorduring function. This technique enables

Fig. 6 : Pre-rehabilitation and post rehabilitation intra-oral

view

Source of Support : Nill, Conflict of Interest : None declared

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Article-PDF-sheen Juneja Aman Arora Shushant Garg Surbhi-530 (1)