Complete Mucostatic Impression: A New Attempt: Keywords
Complete Mucostatic Impression: A New Attempt: Keywords
Keywords Abstract
Denture foundation; flabby ridge; mucostatics;
mucostatic impressions; magnetically retained Hypermobile ridges or flabby edentulous ridges are a common occurrence in edentu-
custom tray. lous patients. The literature reveals that the mucostatic impression technique is one of
the treatment options in this scenario. Conventional mucostatic methods like employ-
Correspondence ing a window tray technique, multiple relief holes, or double spacers can be employed
Y. A. Bindhoo, Department of when the flabby tissue is localized. But in cases of generalized flabbiness of the resid-
Prosthodontics, Sri Ramakrishna Dental ual ridge, even the manual placement and manipulation of a custom tray may distort
College and Hospital, SNR College Rd., Nava the tissues, violating the principle of mucostatics. This presentation is a clinical report
Coimbatore, of a patient with a generalized flabby maxillary edentulous ridge opposing a partially
Tamil Nadu 641006, India. E-mail: edentulous mandibular arch. A split two-part special tray using the principle of mag-
bindhoomds@yahoo.co.in netic attraction for self retention was fabricated. This self retention ruled out finger
pressure during impression making, helping to achieve mucostatics.
Awarded best paper in a session at the 37th
Indian Prosthodontic Society conference,
Thrissur, Kerala, India, 2009.
doi: 10.1111/j.1532-849X.2011.00810.x
Constructing a stable prosthesis to restore missing dental syndrome. Lammie6 and Kelly7 conceded that in cases of com-
and alveolar structures is the objective of complete denture bination syndrome, a single maxillary complete denture plays
prosthodontics. Jacobson and Krol clearly outlined retention, its part in the development of an anterior maxillary flabby ridge.
stability, and support as factors determining the success of a They explained the mechanism behind this by stating that the
complete denture prosthesis.1 A denture foundation composed compressive and rotational forces generated by the standing
of both hard and soft tissue structures plays an important role mandibular teeth are transmitted to the maxilla via the maxil-
in determining these factors. Ideally the masticatory mucosa lary denture, causing resorption of underlying alveolar bone.
overlying the residual ridge must be 1.5 to 2 mm thick.2 Ex- As a result, the overlying mucosal layer loses its bony support
cessive mucosa is a perplexing problem in terms of complete and exhibits excessive displaceability.2
denture construction. The different surgical treatment options available for man-
The Glossary of Prosthodontic Terms defines flabby ridge aging flabby ridges are excision, ridge augmentation, and in-
as excessive movable tissue.3 This excess mobility offers poor jection of scelorosing solutions.2 The prosthodontic manage-
stability and support for the complete denture. MacEntee states ment of these cases can be done to a certain extent by proper
that concerns about support for the denture should be noted recording of these hypermobile tissues and by providing stable
if the residual ridge moves more than 2 mm under light pres- occlusal contacts. Since the 1900s there has been controversy in
sure.4 Massad and Lobel have graded the displaceability of flabby ridge impression making. The issue of compressive ver-
flabby tissues as low displaceability, average clinically accept- sus static philosophy of impression recording prevailed. After
able displaceability, and high displaceability. They indicated the 1930s clinicians supported this latter concept of record-
that the last condition is very difficult to treat.5 ing tissues at rest. The various static methods used over the
Atrophy, bone resorption, nutritional deficiencies, pressure, years include employing spacers or perforations in impression
and functional forces are various etiological agents proposed trays, scraping of impression trays, window technique, and us-
by Desjardin and Tolman for flabby ridge development. Ex- ing detachable trays.8-20 All these methods can be effectively
cessive detrimental pressure on the residual ridge occurs in employed in cases of localized areas of hypermobile ridge tis-
patients with parafunctional habits. On the other hand, nor- sue. The problem is when the flabby ridge is generalized. This
mal functional forces become harmful in clinical situations like presentation deals with the prosthodontic management of a
malrelation of the maxilla to the mandible and when a com- generalized flabby edentulous ridge with the aid of a novel
plete denture opposes the natural dentition, as in combination mucostatic impression technique.
Clinical report as palatal and ridge sections, which will be referred to hereafter
as tray A and tray B, respectively.
A 73-year-old male patient reported to the Department of
Prosthodontics, Sri Ramakrishna Dental College and Hospital,
Coimbatore, India, seeking a new maxillary complete denture Fabrication of tray A.
due to the fracture of the existing denture. The previous den- A single thickness of modeling wax (Surana, Mangalore Den-
ture was made 10 years previously, and the patient had a history tal Corporation, Mangalore, India) was adapted on region A,
of continuous denture wear without allowing tissue rest. He is and tray A was prepared with autopolmerizing resin (DPI–RR
under treatment for hypertension and diabetes. Cold Cure, The Bombay Burma Trading Corporation, Mumbai,
India). Tray A covered all of region A and extended around the
Clinical examination hamular notch region of the cast. Three depressions (denoted
as D1, D2, and D3 hereafter) were developed in tray A; one
Intraoral examination revealed a maxillary edentulous ridge,
anteriorly (D1) and two posterolaterally (D2, D3) (Fig 2A).
classified as class IV according to the American College of
Ferrite magnetic discs (6-mm diameter) (denoted as M) (M/S
Prosthodontists Prosthodontic Diagnostic Index (ACP PDI) for
Sidhi enterprises, New Delhi, India) of 0.35 tesla magnetic field
complete edentulism,21 and a partially edentulous mandibular
were placed in each of the three depressions (magnets in the
ridge with missing central incisors corresponding to ACP PDI
three depressions will be denoted as MD1, MD2, and MD3
class III for partial edentulism.22 The maxillary ridge mucosa
hereafter) (Fig 2B).
was hyperplastic and showed varying degrees of displaceability
(Fig 1A).
Fabrication of tray B.
Treatment plan Tray B was fabricated with autopolymerizing resin after cov-
The patient required the following treatments: ering the hyperplastic ridge in region B with two layers of
modeling wax. The wax was placed 4 mm short of the sulcus,
(1) Scaling and root planing of the remaining mandibular teeth; and the tray was fabricated 2 mm short of the sulcus. Three hor-
(2) Management of flabby ridge, izontal resin extensions (denoted as H1, H2, and H3 hereafter)
(i) surgical or were constructed in tray B to engage the depressions D1, D2,
(ii) prosthodontic; and D3 in tray A (Fig 3A). Another set of three ferrite magnets
(denoted as M) were placed in these horizontal resin exten-
(3) Maxillary removable complete denture and mandibular re- sions (magnets in each of the three horizontal extensions will
movable partial denture (RPD). be denoted as MH1, MH2, and MH3 hereafter) (Fig 3B). The
The main hurdle in managing the situation at hand was a magnets were secured in place with autopolymerizing acrylic
generalized flabby maxillary edentulous ridge. Management of resin.
this in terms of surgery required ridge augmentation, along
with vestibuloplasty as suggested by the oral surgeon. As the Tray assembly
patient’s general health and motivation level did not favor a
Trays A and B were placed in their respective areas on the
surgical option, prosthodontic management in the form of mu-
diagnostic cast. When assembled, the depressions in tray A
costatic impression and stable occlusal contacts were planned.
were engaged by the horizontal resin extensions of tray B. The
custom tray remained stable due to the attraction between the
Treatment procedure unlike magnetic poles of tray A (MD1, MD2, and MD3) and
A diagnostic impression of the maxillary arch was made tray B (MH1, MH2, and MH3). There was a uniform clearance
with irreversible hydrocolloid (Tulip, Cavex, RW Harlem, The of 1 to 2 mm between trays A and B all around, except in the
Netherlands), and the diagnostic cast was prepared with type II areas where the magnets engaged each other (Fig 4).
gypsum product. The mere introduction and placement of the
stock impression tray with finger pressure caused excess tissue Impression making with self-retaining custom
displacement of maxillary residual ridge. Due to the lack of tray
stable area on the ridge, the mode of stabilization of the custom
tray during impression making needed to be addressed. A new The assembled tray was placed intraorally to develop a func-
method, a magnetically retained custom tray, was planned. tional border seal. The very heavy body elastomer (Express, 3M
ESPE, Seefeld, Germany) was used on the borders of tray B
and on the posterior palatal seal region of tray A for functional
Construction of magnetically retained custom
border molding. During this step the tray was stabilized with
tray
finger support over the tray A region. The patient was asked
On the diagnostic cast of the maxillary edentulous ridge, the to perform functional movement to develop labial and buccal
denture-bearing area was divided based on displaceability of borders. At the completion of this step, the trays were detached
tissues as the palatal vault region (Region A—relatively stable) for final impression making. The placement and orientation of
and residual ridge region (Region B with generalized tissue trays A and B in stages were rehearsed many times so the tis-
displacement) (Fig 1B). Corresponding to the same division, sues would be recorded at rest without disturbance from the
the custom trays were made in two parts. They were designed operator’s finger pressure.
Figure 1 (A) Completely edentulous maxillary arch with generalized ridge hyperplasia; (B) Diagnostic cast with the regions marked: region A—palatal
vault, region B—ridge portion.
Figure 5 Two stages of impression making. (A) First stage—Impression making of region A with tray A; (B) Application of impression material for
second-stage impression making of region B with Tray B.
Figure 7 (A) Clear acrylic denture base showing close adaptation to tissues; (B) Insertion of removable maxillary complete denture and mandibular
partial denture.
The light-body elastomer (Express XT Ultra-Light, 3M The partially filled tray B was gently oriented in correct relation
ESPE) was injected over region A, and the impression of this to tray A so the magnets were aligned in line (i.e., MH1-MD1,
portion was completed first with tray A stabilized with finger MH2-MD2, and MH3-MD3). Now when the power of magnetic
pressure (Fig 5A). Maintaining tray A in place on the palate, the attraction was felt, the hold on tray B was released. The tray
low-viscosity elastomer was gently syringed over the displace- was self-retained due to the pull of magnetic force. Finger pres-
able tissues of the ridge only to the extent required (Fig 5B). sure was totally removed. Excess material escaped through the
Figure 2 Fabrication of tray A. (A) Depressions in tray A (D1, D2, D3); (B) Magnets in the depressions (MD1, MD2, MD3).
Figure 3 Fabrication of tray B. (A) Horizontal resin extensions of tray B (H1, H2, H3); (B) Magnets in place on the horizontal resin extensions (MH1,
MH2, MH3).
Denture insertion
spacing between the two portions of the tray. The tray was sta-
bilized with magnetic attraction alone. After allowing sufficient On the day of denture insertion, the mandibular RPD was in-
time for the material to polymerize, the tray was removed in serted first. Utmost care was taken during the insertion of the
one section. maxillary complete denture. The denture was inserted, and
Figure 6 (A) Final impression with magnetically retained custom tray; (B) Master cast of maxillary arch.
signs of tissue rebound were assessed. Disclosing paste was the denture. But when unloaded, the denture loosens because
used to further check for localized areas of tissue loading. blood re-entering the tissue alters its contours. This viscoelas-
Occlusal discrepancies were eliminated (Fig 7B). The denture tic behavior of hyperplastic mucosa affects the retention and
exhibited satisfactory retention and stability. stability of a denture.8-20
The necessity of the patient’s role in denture care and its Although disagreements exist with the original concept of
implications in the progression of the existing soft tissue hy- mucostatics, they are still employed after careful modifications
perplasia was clearly explained to the patient. The patient was because the crux of mucostatics cannot be denied. The concept
recalled initially after 24 hours to check for postinsertion com- says that the soft tissues, especially flabby tissue, should be
plaints. The patient did not report any appreciable discomfort registered in an impression in an unstrained position for the
and was satisfied with the denture fit and function. The pa- reason that any other position will compel the tissues to re-
tient was put on a recall schedule first after 1 month, and then gain their rest position, dislodging the denture.20 But a close
3 months, followed by every 6 months. Occlusion, tissue health, scrutiny will show that it is not possible to record tissues
and progression of soft tissue condition are to be assessed dur- at complete rest for several reasons, as mere introduction of
ing every recall appointment. trays and the direction and amount of force applied by the
finger can result in varying degrees of tissue displaceability.13
Numerous mucostatic impression techniques for recording lo-
Discussion calized areas of hyperplasia have been published.5,14,20,23 Most
Flabby ridges can be managed by prosthodontic management techniques are applicable in the anterior maxillary edentulous
alone or in combination with surgical treatment depending on ridge.
the degree of displaceability.2-20 Surgical excision is favorable In this case, the described mucostatic technique enabled a
if there is sufficient bone height, but most of the time it decreases satisfactory recording of generalized ridge hyperplasia. The
the sulcus depth requiring vestibuloplasty. Ridge augmentation magnetic retention ruled out finger pressure and provided an
by grafting is an invasive treatment option, as it carries with it easy and stable orientation of special trays. The magnets also
the risk of resorption or rejection of graft material along with acted as tissue stops, avoiding overcompression of displaceable
the need for additional surgery for graft harvesting. The idea tissues of crest.
of injecting scelorosing solution to make the tissues firm was Although tissue displacement will occur on loading in the
popularized by Desjardins and Tolman.2 The demerits reported above-stated technique, the displacement is limited to only 2 to
with this concept are anaphylactic reactions, patient discomfort, 3 hours during mastication. In the remaining hours of the day,
loss of firmness in some cases, and technique sensitivity. Factors the tissues are in their natural rest position, and the mucostatic
deciding the suitability of a patient for these surgical treatment denture base will show uniform tissue adaptation. This passive
options are age, general health, dental history, motivation, and denture adaptation will not interfere with the viscoelasticity or
personality.2 the vascularity of the hyperplastic tissue, thereby maintaining
Ideas on impression making of hypermobile tissues have the tissue health.
been presented over the years in relation to just one
consideration—pressure. Pressure on hyperplastic mucosa al-
ters normal tissue balance as per the law of hydrostatics. A
Conclusion
denture constructed from a pressure-type impression can ex-
hibit excellent fit during function. This is because compression A self-retained tray technique aims to record the tissues in
displaces the vascular contents of blood vessels of the tissues their complete passive form, as finger pressure is ruled out.
into the interstitial spaces, and tissues conform to the shape of It is a simpler and less-extensive prosthodontic alternative for
patients with hyperplastic edentulous ridges, where surgical 11. Buckley GA: Diagnostic factors in the choice of impression
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