RestorativeDentistry

Jonathan W Turner

Rebecca Moazzez and Avijit Banerjee

First Impressions Count

Abstract: The art and craft of recording intra-oral anatomy successfully with dental impressions relies on the interaction of three critical
factors – the ‘golden triangle of impression-taking’: an appreciation of the anatomical features to be recorded, the material used to take the
impression and the clinical handling/operative technique applied. This paper aims to discuss the three factors and their inter-relationships,
detailing clinical tips for successful, reproducible and consistent outcomes.
Clinical Relevance: Obtaining accurate dental impressions is the key to success in a wide range of clinical restorative procedures. This
paper offers clinical advice to practitioners to plan and then take predictable, good quality impressions for their restorative cases.
Dent Update 2012; 39: 455–471

This paper aims to cover the clinical aspects of dependent upon the prosthesis to be landmarks outlined in Table 1 is to ensure
planning and impression-taking for fixed and constructed, their clinical relevance and optimal stability, support and retention of
removable prosthodontics, including clinical problems that may be encountered if not the final constructed prosthesis. The British
tips for achieving successful, reproducible incorporated appropriately into the design Society for the Study of Prosthetic Dentistry
and consistent outcomes in routine, as well of the final prosthesis. Figures 1 and 2 show defines retention, support and stability as
as more complex cases. A large number of the position of the important anatomical follows:2
impression techniques have been described.1 landmarks in edentate mouths and suitably  Retention: ‘Resistance of a denture to
The key points are summarized in three fitting and extended trays. vertical movement away from the tissues’.
tables to act as a quick reference tool for The clinical relevance of recording  Support: ‘The resistance of a denture to
readers to obtain information on relevant
anatomy, impression materials and clinical
a a
tips, including illustrative figures. In addition,
there are two flow charts covering the mind-
mapping process of planning and executing
primary and secondary impression techniques
for the construction of complete dentures.

Anatomical landmarks
Table 1 summarizes the
anatomical features that need recording
b b

Jonathan W Turner, BDS, MSc, MA(Ed),

Senior Clinical Teacher/Specialist in
Prosthodontics, Rebecca Moazzez, BDS,
MSc, FDS RCS(Eng), FDS(Rest Dent), PhD,
MRD, FHEA, Senior Lecturer/Specialist
in Restorative Dentistry and Avijit
Banerjee, BDS, MSc, PhD(Lond), FDS(Rest
Dent) FDS RCS(Eng), FHEA, Professor of
Cariology & Operative Dentistry, Hon Figure 1. (a) Anatomical landmarks in the Figure 2. (a) Anatomical landmarks in the
Consultant in Restorative Dentistry, King’s maxillary edentate arch (A – incisive papilla; mandibular edentate arch (A – retromolar pad;
College London Dental Institute at Guy’s B – maxillary tuberosity; C – fovea palatinae; B – retromylohyoid fossa; C – buccal shelf; D –
Hospital, KCL, King’s Health Partners, D – hamular notch). (b) A suitably fitting and residual alveolar ridge crest). (b) A suitably fitting
London, UK. extended maxillary special tray. and extended mandibular special tray.

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Anatomical Landmark Clinical Relevance Comments

to Prosthesis

Residual alveolar Stability (if ridge  Fibrous ridge. Special techniques may be required, such as use of windowed trays.
ridges well formed) and  Sharp ridges/bony spicules may require surgical removal prior to impression-taking or
support necessitate relief of the fitting surface or use of a soft lining.
 Bony undercuts necessitate use of an elastic impression material such as silicone, as opposed to
a non-elastic material such as ZOE.
 If mandibular ridge resorption great then satisfactory stability will be hard to obtain.

Hard palate (Mx) Provides support  Centre of posterior hard palate is a primary area of support.
for denture  Denture must be closely adapted to palate to assist with retention.
 The ‘vibrating area’ is located on the soft palate near its junction with the hard palate. The
posterior border of the denture (the ‘post-dam’ region) extends to this area in order to achieve
the posterior seal required for adequate retention.
 A very shallow palate may cause problems with stability.
 Care is needed with high vaulted palates, to ensure that the impression material accurately
records the full vault.
 If tori present, the fit surface of denture may need to be relieved to prevent mucosal trauma. If
the tori extends back to the post-dam region, posterior seal may be difficult to obtain.

Incisive papilla (Mx) Biometric guide  If alveolar ridge is very resorbed the papilla may lie on ridge crest.
for anterior tooth  Labial face of maxillary incisors usually positioned 8−10 mm anterior to centre of papilla.
position

Fovea palatinae (Mx) Guide to position  Guide to position of displaceable tissue (‘vibrating area’) in the palate.
of posterior border  Lie in the soft palate, usually slightly posterior to ‘vibrating area’.
of special tray/  Tray should extend just distal to the fovea so they are recorded. Failure to do so will result in
denture under-extended denture which lacks a posterior seal and thus retention.

Hamular Guide to position  A guide to position of displaceable tissue.

notches (Mx) of posterior border  Posterior border of special tray/denture should rest in these notches in order to obtain a
of special tray/ posterior seal.
denture  If denture extends distal to the notches it will interfere with the action of the pterygomandibular
raphe.

Retromolar Seal/retention  Posterior border of mandibular complete denture will extend 1/2 to 2/3 up pads, displacing
pads (Md) them and helping to provide a seal.

Retromylohyoid Stability  Engaged bilaterally by the disto-lingual part of the mandibular denture flange.
fossae (Md)  Located distal to attachment of the mylohyoid muscle.
 Greenstick composition can be added to fit surface of the special tray in this region to ensure
impression records fossae accurately.

Buccal shelves (Md) Support  Located between alveolar ridge crest and external oblique ridge.
 Cortical bone provides primary support for a mandibular complete denture.
 The more the mandibular alveolar ridge resorbs, the wider this shelf becomes.11

Mylohyoid ridges (Md) Retention (via border  Lingual aspect of mandible-mylohyoid muscle attaches to these.
seal) and stability  With alveolar ridge resorption the mylohyoid ridge will lie near the ridge crest posteriorly.
 Sharp ridges may lead to the overlying mucosa being traumatized by the denture, unless the
fitting surface is relieved, or the ridge smoothed surgically.
 Lingual flange of denture needs just to cover these ridges; the inferior border of flange contacts
the contracted mylohyoid muscle, helping to achieve a border seal.

Buccal sulci Denture flange  Denture flanges need to fill sulci to achieve peripheral border seal.
extends into sulcus  Often sulci widest in the region buccal to the maxillary tuberosities.
to obtain a peripheral  The greater the resorption from the buccal aspect of the alveolar ridge, the greater the width of
seal (retention) and the sulcus.
assist stability.  Advancing coronoid process and the contracted masseter muscle will reduce the sulcus
width.11

Lingual sulci (Md) Denture flange  Border seal is difficult to obtain lingually owing to the movement of the floor of the mouth as
extends into sulcus in mylohyoid contracts. Aim is to achieve a seal when floor of the mouth is in raised position.
attempt to obtain a  If alveolar ridge resorption has taken place the lingual sulcus may be very shallow and care is
peripheral seal needed to ensure the flange is not over-extended.
(retention) and assist  Over-extension into the lingual sulci results in denture displacement as the floor of the mouth
with stability. raises during function.
 Large lingual tori in the premolar region may require surgical removal or adequate extension of
denture will not be possible.

Fraenum Denture will be  Found midline labially and lingually and also mid-buccal.
notched around  If denture impinges, trauma will result and the denture may be displaced in function.
fraenae.  Fraenal attachments may lie close to the alveolar ridge crest (for example following extensive
ridge resorption) impairing border seal and functional stability.
Table 1. Summary of anatomical landmarks and their clinical relevance in prosthesis construction (Mx – maxillary; Md – mandibular).

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occlusally-directed loads’. such as Perform®-ID (Schülke & Mayr UK Ltd,

 Stability: ‘The resistance of a denture to Sheffield, UK) for ten minutes. Following
displacement by functional forces’. removal from the disinfectant, re-rinse
When a patient complains that and store appropriately (Table 2). When
his/her denture is ‘loose’, it is important to completing the laboratory prescription it
establish whether the cause is due to a lack must be confirmed that disinfection has been
of retention, support or stability (or, more carried out.
commonly, a combination of all three). Often
problems associated with these properties
Removable prosthodontics
are related to inadequate denture-base
extension, in turn, a consequence of faults Primary impressions (Figure 3)
with impression technique. For example, a The purpose of the primary
maxillary complete denture covering only impression is to enable study model
half of the hard palate will have reduced manufacture and construction of custom-fit
support but, as it does not extend posteriorly special trays for both the partially dentate or
onto displaceable tissue (the ‘vibrating edentate patient.
area’), it will also lack seal and thus retention. With edentulous cases, these Figure 3. Maxillary silicone putty primary
Similarly, an under-extended lower complete impressions enable the areas involved with impression with recorded landmarks (A – incisive
denture failing to cover the buccal shelves denture support to be outlined as well as the papilla; B – maxillary tuberosity; C – hamular
will lack support; or failing to engage the correct extensions for the special trays – the notch).
retromylohyoid fossae will reduce its stability. latter helping facilitate a peripheral seal in the
completed denture (Table 1). If the primary
impression for an edentulous case fails to
Impression materials meet these criteria it will prove impossible to 2). Silicones or impression composition alone
record a satisfactory secondary impression – can also be used for edentate mouths. An
This paper does not aim to give
hence the first impression not only counts but advantage of silicone putty is that it also
the reader a full discourse in the detailed
is crucial for success. serves to extend the stock tray should it be
materials science of individual impression
With partial denture cases, casts under-extended. If surface detail is inadequate
materials. Instead they are advised to consult
can be surveyed and provisional designs having used putty, a thin wash of light-bodied
existing authoritative texts in this field. Table
drawn up, having assessed features such as: silicone or alginate (using an appropriate
2 summarizes the clinically relevant issues
 Presence of naturally occurring guide adhesive) may be applied to the fit surface of
regarding the use and handling characteristics
planes; the set putty and the tray re-inserted.
of a range of materials used in prosthodontic
 Tooth and hard tissue undercuts; Care is required when taking an
practice to record anatomical landmarks.
 Depth of sulci; impression as regards operator and patient
 Position of fraenal attachments; positioning and the method used to seat
Clinical techniques  Space available to bring metal components, the tray. For the upper impression, with the
Infection control such as restseats or clasp arms, over the patient sitting upright, the operator stands
Prior to casting an impression, occlusal surface. behind the dental chair looking down over
it must be disinfected without losing Metal or plastic disposable the patient’s head as the tray is rotated into
dimensional stability and care must be stock trays can be used, though the former position to ensure that the tray handle is
taken to follow manufacturer’s instructions are losing popularity owing to difficulties positioned centrally. The anterior part of the
with respect to timings – less than the in sterilization. The flanges of plastic trays tray is seated first so the amount of material
recommended time will lead to inadequate can be trimmed easily if overextended or flowing from its posterior edge can be
disinfection, whereas an excessive time silicone putty or wax is used to modify them if monitored visually. With the lower impression,
period may cause distortion of the impression underextended. It is important to ensure that the operator stands in front of the patient
material. the selected trays are tried in the mouth and and rotates the tray into place, ensuring its
Once removed from the mouth, assessed carefully to ensure that they engage alignment centrally. Care must be taken to
impressions should be rinsed thoroughly left and right sulci simultaneously, but are not avoid trapping the tongue with the lingual
under water until visibly clean then inspected so wide as to distort the buccal mucosa. Their flanges by asking the patient to protrude the
to ensure all details have been recorded. It length should also be assessed to ensure that tongue such that its tip rests on the lower lip
is important to check that the material has they cover the landmarks required (Table 3). as the tray is seated. It is important to remove
not pulled away from the tray, leading to Alginate is used commonly for flexible impression materials from the mouth
inaccuracies (with perforated trays ensure primary impressions. Prior to using alginate, using a snap movement to avoid deforming
that the material has flowed through the in partially edentulous cases, silicone putty the material.3
perforations). Disinfect using an appropriate or impression composition can be used to
method for the advised time period, eg customize the stock tray by adding it to large Special trays
immersion in a proprietary disinfectant saddle areas or in the palatal region (Table In a survey of general dental

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Material General Factors Technique Surface Detail Dimensional Stability

Alginate Cheap: can pour once. Adhesive and perforated tray. Excellent Once disinfected, store in 100%
Available in sachets/bulk. Ensure correct powder: water humidity (sealed plastic bag
Available with different ratio. Increased water covered in damp gauze) and cast
speeds of set. temperature will decrease as soon as possible.
Modern alginates setting time.
dimensionally stable over five Remove from mouth with
days.20 snapping action.

Silicone Use to modify stock trays Easy to use. Wear non-latex Poor (thus a need Good. Store dry until cast.
putty (eg in palatal vault or large gloves to mix. Useful in for a wash
saddle areas, defects) or gagging patients as flow impression
borders of special trays. controlled easily and can when used for
Use as part of putty/wash remove before fully set in edentate recording crown
technique for fixed cases. Take care not to use excess impressions).
prosthodontics. quantities as viscosity may
lead to over-extended
impressions and sulci
distortion.

Light- Use in conjunction with Used in a gun/dispenser. Excellent Good. Store dry until cast.
bodied putty or heavy body
silicone silicone for crown and bridge
preps or as a jaw registration
material.

Medium- Multiple casts possible. Hand or machine mixed. Excellent Good. Store dry until cast.
bodied Can be used by itself as an
silicone impression material.

Polyether Accurate, dimensionally stable, Do not use in special trays. Excellent Good. Store dry until cast.
single stage and consistency,
used for implant pick up imps.

Zinc Ensure patient is neither No adhesive required. Excellent Good. Store dry until cast.
Oxide allergic to eugenol nor Can use for complete denture
Eugenol suffers from xerostomia. secondary impressions, but
paste Petroleum jelly needed on not in dentate mouths. Ensure
(ZOE) patient’s lips. Messy. Warn tray dry. Can add further ZOE
patient of strong taste and over top of existing set material
possible burning sensation. to correct minor defects/air
Non-elastic, unsuitable for blows. Can use for recording jaw
deep bony undercuts. registrations in conjunction with
wax occlusal rims.

Impression Cheap. Easy to use − no Quick impression − suitable if Adequate for Poor − high coefficient of thermal
wax mixing required. poor patient compliance. occlusal jaw reg. expansion causing distortion.
Used to modify trays or as
jaw reg material.

Greenstick Practice required to use this Use heat to soften, so it will flow, Adequate for tray Good
composition material effectively. Once trace around required region of modification.
cooled, material is hard and tray then temper in warm water,
brittle. Good for correcting prior to placing in patient’s mouth,
under-extended special trays to avoid burning patient.
and border moulding.

Table 2. Impression materials: physical characteristics and operative techniques.

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What are you Anatomical Features Materials/Tray Design Common Problems and Solutions/Tips
Constructing? Recorded

Study models  Tooth surfaces  Alginate − stock tray  Air-blows and drags on occlusal surfaces: apply alginate
 Sulci to dried occlusal surfaces of teeth with fingers prior to
seating tray.

Single crown  Preparation  Polyether − stock tray  Poor recording of preparation margins. Use gingival
 Tooth surfaces of  Silicone (in a range of formats) − stock or retraction cord if sub-gingival. If using putty/wash
other teeth in arch/ special tray technique ensure the intra-oral wash has not set prior to
opposing arch The materials suitable for a single stage and seating putty.
single consistency impression are either  Exercise care when using polyether in custom-made
polyether or a medium-bodied addition trays as undercuts could be engaged if not blocked out,
cured silicone. resulting in difficulty in removing the tray from the
Materials suitable for dual consistency mouth once set.
impressions can be used in the following
combinations:
– Light/medium body silicones
– Light/heavy body silicones
– Light body/putty silicones
– Medium/heavy body silicones
– Medium body/putty silicones
– Alginate for opposing arch-stock tray

Bridge As for crown, plus As for crown
saddle areas

Implant-supported  Fixture/abutment  Polyether in stock tray. Can use silicone and  Impressions made at fixture-head level or the abutment,
restorations and surrounding stock/custom-made tray as per crowns and depending on the type of abutment/restoration. Consider
soft tissues, rest of bridges. the occlusion, angulation and position of the implants.
the arch. Opposing  Impressions made either as an open-tray or closed-tray
teeth. technique. If using open-tray technique, ensure that
impression material is removed to expose the screw before
set.

Complete  Upper  Alginate and/or silicone putty in stock tray  Flanges of plastic stock tray over-extended: trim them back
dentures: – Residual alveolar ridges (cover rough surfaces with red ribbon wax).
Primary – Sulci  Stock tray does not cover all necessary landmarks: use
impression – Palate silicone putty to modify tray extensions.
(see Figure 12a) – Maxillary tuberosities  High-vaulted, ‘V’-shaped palate − modify stock tray with
– Hamular notches silicone putty.
– Fovea palatinae  Tongue trapped under lingual flange of tray: ask patient to
– Incisive papilla lift tongue as mandibular tray seated.
– Fraenae  Lingual sulcus incorrectly recorded: ask patient to protrude
 Lower his/her tongue to lip once mandibular tray has been seated.
– Residual alveolar ridges  Poorly recorded labial sulcus − check tray position ensuring
– Sulci labial flange is in sulcus and lip not trapped. Ask patient to
– Retromolar pads half close so lips not taut.
– Buccal shelves  Gagging patient: consider using silicone putty rather than
– Retro-mylohyoid fossae alginate.
– Fraenae

Complete As for primary impression  Alginate − spaced, perforated special tray  Check tray extensions to ensure all necessary landmarks
dentures:  Zinc oxide eugenol (ZOE) − close-fitting, are covered. Greenstick composition can be used to correct
Secondary non-perforated special tray under-extended trays or to border-mould the periphery.
impression  Silicone − close-fitting or spaced non-  Border-mould tray using ZOE, by tracing the material
(see Figure 12b) perforated special tray around the periphery of the tray and intra-oral moulding.
Once the moulded material has set, a wash of ZOE applied
to the entire fit surface of the tray and impression taken.
 As with primary impression, ask patient to raise tongue on
seating mandibular tray then protrude it.
 With alginate ensure it is well retained in tray using
perforations and appropriate adhesive.1 A disadvantage of
alginate secondary impressions in edentulous patients is
that it can be difficult to control its flow accurately, causing
inaccuracies in the recording of the sulcus.
 Silicone needs a viscosity that will flow (a medium-bodied
appropriate) and adhesive must be added to the tray.
 As it is an elastic material it is appropriate to use silicone in
cases with undercuts (eg buccal to tuberosities). Do not use

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in-elastic materials such as ZOE in these cases.

 Avoid ZOE in xerostomic patients.

Partial dentures  All tooth surfaces  Alginate and/or silicone-stock tray  Poorly recorded palatal vault − modify stock tray with
Primary – Sulci silicone putty in palatal region prior to making alginate
impression – Palate impression.
– Saddle areas  Poorly recorded labial sulcus − check tray position ensuring
 Lower free-end saddle labial flange is in sulcus and lip not trapped. Ask patient to
dentures: half close so lip not taut.
– Buccal shelves  Lingual sulcus incorrectly recorded − ask patient to raise
– Retromolar pads tongue as tray is inserted, to avoid trapping it. Once tray
– Retromylohyoid fossae seated ask patient to protrude tip of tongue to lip so floor
 Upper free-end saddle of mouth is recorded in raised position.
dentures:
– Tuberosities
– Hamular notches

Partial dentures As for primary  Alginate − spaced, perforated special tray  Impression material pulls away from tray − ensure
Secondary impression  Silicone − spaced, non-perforated special tray adequately perforated if alginate. Use correct adhesive in
impression manner specified by manufacturer.
 Care needed to ensure all teeth/structures involved with
the denture design are recorded clearly (eg occlusal rest
seats).
Table 3. Impression techniques related to the clinical relevance/requirements of the situation.

a and whether features such as windows are denture retention, Darvell and Clark discuss
required (see the anterior fibrous change the importance of close adaptation of the
section). Such decisions will depend in part denture base to the underlying tissues and
upon the chosen impression material and the relevance of impression technique in
the nature of the denture-bearing tissues achieving this.5
(Table 3). Appropriate spacing would be 3 Necessary modifications are made
mm for alginate and 2 mm for medium or to the special tray, reducing over-extensions
low viscosity elastomers4 and close-fitting for with an acrylic bur and correcting under-
zinc oxide eugenol. With edentate arches the extensions using additions of greenstick
advantage of close-fitting, non-perforated composition/silicone putty. Greenstick
trays is that it is readily apparent, when the composition can be used to border-mould
tray is tried in, whether modifications are the tray by tracing it incrementally around
b
required. A correctly extended maxillary tray the periphery, tempering in warm water then
(possibly with the addition of appropriate massaging the surrounding musculature
border tracing material such as greenstick whilst holding the tray in place. This moulding
composition) should exhibit similar retentive can also be achieved by asking the patient to
properties to the final denture base as a contract his/her oral musculature by pursing
peripheral seal can be obtained, whereas if a the lips and offering a broad smile. These
Figure 4. (a, b) Upper and lower close-fitting,
perforated tray is used, such a seal will not be techniques will ensure that the periphery of
non-perforated special trays with stub handles, possible. Stub handles, rather than L-shaped the tray has adequate thickness, thus helping
seated on study casts. ones, are preferred in edentate arches, as they to achieve the desired peripheral border seal
do not cause distortion of the lip or errors in in edentate cases.
recording the labial sulcus (Figure 4). The posterior extension of
the edentate maxillary tray needs careful
practitioners, 75% reported using laboratory-
assessment to check that it extends to cover
constructed special trays to make their Secondary impressions
the necessary landmarks (Tables 1 and 3).
complete denture secondary impressions, The purpose of the secondary
Greenstick composition can be added to the
with much variation in their design.1 impression is to record the denture-bearing
fit surface in this distal post-dam region in
Decisions need to be made concerning area and relevant abutment teeth. In addition,
order to displace the underlying tissues and
the design of the special tray and these the tissues in contact with the denture base
help facilitate a posterior border seal in the
decisions communicated effectively to the during function and the sulci, with the lips
completed denture (Figure 5).
laboratory. Such decisions include whether and cheeks supported, must be recorded
In edentate cases, the disto-
or not to perforate the tray, the amount, if (RKF Clark – personal communication,
lingual extension of the mandibular tray is
any, of spacing needed, the handle design 2010). In their explanation of complete
crucial. The lingual flange should rest against
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a 2010 – personal communication). In many

cases, operator error is the cause as a result
of overloading the tray with impression
material. The following practical tips may help
overcome this problem:
 Take care when seating the maxillary tray
to observe how much material flows from
the posterior edge of the tray. If an excessive
amount appears then stop seating the tray,
allow the material to set, remove and repeat
with a reduced quantity of material.
 Use silicone putty to modify the stock
Figure 6. A mandibular secondary impression tray, thus reducing the quantity of alginate
recorded in a medium-bodied silicone with required and the likelihood of excess material
b anatomical landmarks highlighted (A – residual being extruded.
alveolar ridge; B – buccal fraenum; C – buccal  Use fast-setting alginates or warm water to
shelf; D – retromolar pad; E – retromylohyoid reduce the setting time.
fossa).  Distraction techniques, such as asking the
patient to raise his/her feet from the chair,
nasal breathing if possible, can be effective.

a mandibular secondary impression recorded

with a medium-bodied silicone. Anterior fibrous change
If lower anterior teeth occlude
Figure 5. (a) Greenstick addition in the post- against an edentulous maxillary ridge, then
Study casts
dam region of the maxillary special tray and (b) fibrous change to the maxillary anterior ridge
retromylohyoid fossa region of the mandibular
Study casts can be used to/for:
can occur over time. Use of a conventional
special tray.  Assess the occlusion;
impression technique is likely to result in
 Diagnostic wax-ups;
displacement of this ridge, which in turn
 Monitor toothwear;
may lead to an unretentive denture. One
 Construct templates for temporary crowns/
the floor of the mouth when the mylohyoid method for overcoming this problem involves
bridges;
muscle is contracted to obtain a seal and must constructing a close-fitting special tray with
 Trial preparations.
extend into, and contact, the medial aspect of a window cut out over the area of fibrous
In cases where an accurate
the ridge in the retromylohyoid fossae (Figure change. The impression is taken in two stages.
impression is not possible in a stock tray, a
5). See Table 3 for tips on how to achieve this. Firstly, a wash of material is applied to the fit
custom-made special tray may be indicated. If
Having completed necessary surface and the tray seated. When set, the tray
there is an adequate number of teeth present
modifications to the special tray, as outlined is removed and any material that has flowed
and intercuspal position (ICP) is stable, it
above, the impression can then be made into the window area is cut away using a
should be possible to articulate the models
using the material of choice (Tables 2 and 3). scalpel. The tray is then re-seated and held in
without the need for an occlusal registration.
For partial dentures, alginate or a medium- place while a low viscosity material, such as
However, if ICP is not stable, or the occlusion
bodied, addition-cured silicone are the ZOE or light-bodied silicone, is painted over
needs to be assessed in retruded contact
materials of choice. Prior to using these the exposed window area. Once set, the tray is
position (RCP), an occlusal registration is
materials, any necessary tooth alterations, eg removed and the resulting impression should
essential. This can be registered in RCP or ICP
guide plane or rest seat preparations, must be have recorded the area of fibrous change in an
using pink wax, beauty wax, silicone materials
completed. un-displaced state.
or zinc oxide eugenol (ZOE). In cases where
As with the primary impression, Lynch and Allen describe a
detailed analysis of the occlusion is necessary,
it is important to ensure that the quantity of technique which involves constructing a
registrations are also needed in lateral
material used is assessed carefully. If a close- special tray with additional spacing and
excursions and protrusion.6,7
fitting tray is used in an edentate mouth, only perforations in the area of displaceable
a thin wash of impression material is required. tissue.8 A heavy-bodied addition cured
Once the tray is seated, the tissues should be Management of the gagging patient polyvinylsiloxane is used to record the ‘normal’
massaged to facilitate border moulding of The patient that gags during denture-bearing tissues and is applied to the
the impression. For the lower impression, the impression-taking can present a challenge. tray periphery. Once set, any excess material is
patient should raise his/her tongue and rest There may be underlying systemic causes removed from the area of displaceable tissue
the tip on the lower lip such that mylohyoid resulting from stomach problems or excessive and light-bodied polyvinylsiloxane is applied
contracts and the floor of the mouth is alcohol and tobacco use, but psychological over the whole fit surface of the tray and the
recorded in the raised position. Figure 6 shows factors often also play a role (RKF Clark, tray re-seated.
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describes a modification to this replica a mandibular complete denture can be set

technique for patients with a displaceable within it, thus assisting its stability. This can
anterior maxillary ridge.10 The base of be helpful in patients that have powerful oral
the replica denture is constructed of a musculature or poor neuromuscular control.12
solid material, such as cold or light-cured Firstly, undertake conventional
polymethylmethacrylate (PMMA) and, having impression and jaw registration stages.
completed the wash impression within the Construct a mandibular baseplate with
maxillary denture using a medium-bodied vertical stops attached to the upper surface
material, a window is cut out over the area that contact the maxillary wax try-in denture
of displaceable tissue and a light-bodied at the pre-determined OVD.13 A wire running
Figure 7. A silicone putty impression sandwich impression material syringed into the window between these vertical stops allows a visco-
copy of an upper complete denture. to record the anterior ridge in an undisplaced elastic material (eg temporary soft lining
state. material) to be retained.
The surrounding musculature
moulds the impression material resulting in
Replica/copy technique
Reline/rebase impression (complete dentures) an outline indicating where the ‘neutral zone’
There have been numerous
One must always question the lies. Further details of this technique and the
methods utilized to replicate dentures.9 Most
desirability of relining or rebasing a denture associated laboratory work are outwith the
involve taking an impression of the fit and
as there is a risk that, unless care is taken, scope of this paper.
polished surfaces of the denture to be copied
both clinically and in the laboratory, the
and then a reline impression taken within the
orientation of the occlusal plane and the OVD
copy. Altered cast technique
may be altered in an undesired fashion.
Prior to making the copy of the In mandibular Kennedy Class I and
Firstly remove any undercuts on
original denture, any under-extended borders II cases, with distal free-end saddles, a cobalt-
the fit surface of the denture using a bur to
should be corrected as outlined above. chromium denture will be tooth and mucosal
enable the laboratory to remove the denture
A large stock tray is filled with the borne. As the support offered by the teeth
from the cast.
material of choice (alginate or silicone putty) differs from that offered by the mucosa, there
To reduce the risk of altering the
and the denture embedded in it, polished is a theoretical possibility that, if an impression
OVD or occlusal plane orientation, a thin
surface down, to a level just short of the top is made of the distal free-end saddle tissues
wash of flowable impression material should
of the flanges. A laboratory silicone putty in an undisplaced state, then during function
be used (eg ZOE or a light-bodied addition-
material is the authors’ material of choice as the denture may sink down into the tissues in
cured silicone) and care taken when seating
it is less costly than silicones for intra-oral use this region.This difference in support may be
the denture to ensure the occlusal plane is
and is more dimensionally stable than alginate overcome by using the altered cast technique,
unaltered.
(Figure 7). which involves altering the edentulous section
Both a closed and an open-
Once set, apply a thin smear of of the master cast.14
mouthed technique have been described, the
petroleum jelly to the top of the impression. Having tried in the metal
former involving the patient lightly closing
A second large impression tray is filled with framework successfully, close-fitting, self-cure
together against the opposing denture in
impression material and seated over the acrylic saddles are attached to the distal of
the position of maximum intercuspation and
fitting surface of the embedded denture, thus the framework such that their extension is the
the latter treating the denture like a special
sandwiching it. same as that of a lower special tray, extending
tray, with the impression recorded with the
Once set, the two impression trays into the retromylohyoid fossa region, over
patient’s mouth open.11 It is important to
can be separated and the denture retrieved; the retromolar pads and covering the buccal
appreciate that the process may result in
any attached greenstick composition is shelves.
movement of one denture relative to the
removed and the denture returned to the A thin wash of ZOE or light-bodied
other with a consequential effect on the
patient. silicone is applied to the fit surface of the
occlusion. Whichever technique is used, it is
At the second clinical visit, tray and the metal framework placed into
important, following return of the denture
an impression is made of the patient’s the patient’s mouth, ensuring the framework
from the laboratory, to re-assess the occlusion
denture-bearing tissues using ZOE or a light- is fully seated, with rest seats engaged, and
carefully and to undertake any necessary
bodied silicone wash impression within the finger pressure applied to the metal work
adjustments.
constructed replica and a jaw registration (but not to the saddle area). This technique
taken. It has been suggested that this will then result in an impression of the
impression should be made before the jaw ‘Neutral zone’ technique distal tissues in the displaced state and the
registration, as the impression material may The neutral zone is defined as ‘a laboratory can undertake the cast alterations.
lead to movement of the denture, in relation zone in which the forces of the cheeks and The altered cast technique is
to the underlying ridge, thus potentially lips are said to be in equilibrium with those used today less commonly, in part because
affecting occlusal vertical dimension (OVD) of the tongue’.2 Impression techniques exist if silicone putty is used during the primary
and occlusal plane orientation.9 McCord to determine its location so that the teeth on impression stage it tends to produce the

September 2012 DentalUpdate 465

 RestorativeDentistry

desired displacement of the distal tissues, and attention needs to be given to the margins,
in part because of the need for an additional ensuring no inclusion of air bubbles, the
clinical visit which provides a questionable dimensions of the prepared teeth should
clinical advantage. be compared between the impression and
the teeth intra-orally and the presence of
any areas where the tray material is showing
Fixed prosthodontics through noted, as this could introduce errors
This section covers impression in occlusion.17
techniques used for indirect restorations such If the preparation margins
as crowns, inlays/onlays, veneers and bridges. are subgingival, it can be difficult to keep
Figure 8. A silicone impression using the putty the area clean and dry to ensure that the
An indirect restoration can only be as good and wash technique. (Courtesy of WNN Wan Nik.)
as the impression of the preparation itself. An hydrophobic flowable impression material
accurate impression will be required of: spreads, covers and records the margins
 All margins and surfaces of the preparation faithfully. Hydrophilic wash materials have
to enable fabrication of the prosthesis in the been developed to try and overcome these
laboratory; problems. If the margin has to be placed
 Proximal surfaces of adjacent teeth to subgingivally, the gingivae need to be
ensure appropriate contact areas are achieved; retracted so that an accurate impression can
 Occlusal surfaces of all teeth in the arch be made. Retraction can be carried out by:
and the opposing arch to enable articulation  Gingival retraction cord (with or without
of maxillary and mandibular casts and thus astringent)18 (Figure 9);
correct contouring of the occlusal surface of  Injectable materials containing aluminium
the crown or bridge being constructed. Figure 9. Retraction cord in position separating chloride for haemostasis and for preparation
the soft tissues from the hard tissue marginal margins within the gingival crevice.
preparations. (Courtesy of WNN Wan Nik.)
Working impressions for crowns and bridges
Often, when there is a fault in the Impressions for temporary crowns and bridges
fit of a restoration, contact areas or occlusion, Impressions used as a matrix for
the problem usually lies with the impression prefer to use the dual consistency – two construction of temporary restorations can
rather than a laboratory fault.15 In a cross- stage method, where the impression is be made in either alginate or silicone putty.
sectional survey, considerable variation was normally taken in putty and allowed to set Alginate is accurate, quick and cheap.19 The
found in the quality of the dental casts as then removed, light-body silicone syringed advantage of silicone putty is that it is firm,
a result of poor impression quality.16 The around the preparation and the impression making the process of temporary restoration
materials used commonly for recording re-inserted in the mouth. If this method is construction easier and more reliable. It
the working impression are addition-cured used, it is essential that the impression is cut is also dimensionally stable and therefore
silicones and polyethers (Table 2). A variety of back or a spacer incorporated in the region can be stored, while the final restoration
techniques can be used with addition-cured of the preparation to allow space for the new is being constructed in the laboratory in
silicones: light body material before re-inserting in the case a remake of the temporary restoration
 Single consistency; mouth. becomes necessary.
 Dual consistency, one stage; There needs to be good
 Dual consistency, two stage. co-ordination between the dentist and the Impressions for implant-supported prostheses
All the above can be carried out nurse to ensure that, as soon as the process of It is beyond the scope of
either using stock trays or custom-made syringing the material is completed, the tray this paper to go into great detail about
(special) trays. The important points to loaded with impression material is ready for impression techniques for implant-
remember when choosing a technique are insertion. If the light-body material is syringed supported restorations. The main points to
that the impression of the preparation needs too early, it will start setting before the note are:
to be as accurate as possible. This is usually impression tray is inserted, resulting in a ‘drag’.  Implant fixture-head impressions can be
achieved by using a flowable material to Also prior to syringing, the preparation needs used to choose the abutments or construct
record surface detail. The bulk of the material to be completely dry with no contamination restorations;
needs to provide adequate rigidity and with water, saliva or blood. The material needs  Abutment-level impressions can be used
support and this is achieved by using a stiffer to be syringed with care, ensuring that the tip to construct restorations;
material. of the syringe is constantly embedded within  The open tray (‘pick up’) technique is
The authors prefer the light/ the impression material to avoid introduction accurate as the impression copings are
heavy-body silicone (Figure 8) or a single of air bubbles. The impression needs to be retained in the impression;
consistency polyether – one stage impression, inspected to ensure an accurate impression  In cases where access is difficult, a closed
as they tend to provide the accurate and is taken of the prepared teeth, as well as all tray (‘reseating’) method can be used but
predictable impressions. Some dentists the teeth in the rest of the arch. Particular the copings remain in the mouth and will
466 DentalUpdate September 2012
 RestorativeDentistry

a There is no doubt that errors

can be introduced during impression-taking,
model pouring, die trimming and restoration
construction extra-orally. In most cases, these
are minor and traditional methods provide
accurately fitting restorations. Since the
introduction of CAD/CAM to dentistry in 1980,
various chairside and laboratory procedures
have become widely available and popular.20
These techniques offer advantages over
b Figure 11. A polyether impression with traditional methods by reducing errors and,
impression copings retained in the final
in the case of chairside systems, providing
impression once the guide pins have been
patients with highly aesthetic restorations in a
released. (Courtesy of WNN Wan Nik.)
single visit.

Chairside CAD/CAM restorations

touching the sides of the tray, after being A hand-held scanning device
screwed in place directly on the implant is used to scan the tooth intra-orally for
fixture heads or abutments. The tray the chairside systems, or a model for the
c windows are covered with wax to control the laboratory systems. The preparation needs
impression material. to be smooth with rounded corners and of
 A rigid impression material (eg polyether) adequate width in order to ensure an accurate
is syringed around the impression coping and scan is obtained. Soft tissue retraction and
also placed in the tray. a dry field are crucial for these systems as
 The impression tray is placed in the mouth there is very little margin for error. There is no
and the guide pins are felt through the wax. impression stage which is an advantage for
This is very important as the guide pins need patients who suffer from gagging, no need for
to be unscrewed before the impression can be a temporary restoration, no laboratory costs
Figure 10. (a) Impression coping guide pins removed from the mouth. for the chairside systems, no model or die
screwed into implant fixture head. Note the  Once set, the guide pins are unscrewed and pouring or trimming. The restoration is then
length of the guide pins in the open tray the impression is removed. The impression made in a milling device (Cerec 3 (Sirona), IPS
technique. (Courtesy of PremaSukumaran.) (b) copings will remain in the impression (Figure Empress CAD (Ivoclar-Vivadent), Paradigm
The maxillary tray has windows cut out of it to 11). (3M ESPE)). Various materials, including
permit the long guide pins to pass through.
resin composites, ceramics and zirconia,
(Courtesy of PremaSukumaran.) (c) An example
are available for inlays/onlays, veneers and
of a mandibular open tray technique permitting Closed tray method
access to the four guide pin screws which can be crowns. There is a steep learning curve for
 The tray does not need to be modified
loosened once the impression material has set, the use of these systems and the cost of the
for the closed tray (reseating) technique.
before the tray is removed. (Courtesy of WNN capital investment needs to be balanced
Impression copings are secured to the
Wan Nik.) against the usage.
fixture head and the impression is taken and
removed as per conventional crown and
bridge technique. The impression copings are Laboratory CAD/CAM systems
then removed and reseated in the impression. This technique requires two visits.
need to be removed from the mouth and
 The impression needs to record accurately The first visit is either for impression-taking
reseated into the impression. There is a risk of
the fixture/abutment, surrounding gingival or a direct scan of the preparation in the
introducing inaccuracies during this process.
tissues, adjacent teeth and soft tissues, as well mouth. The scan or the impression is then sent
as occlusal surfaces of the rest of the arch. to the laboratory. If an impression is taken,
Open tray method  Fixture/abutment analogues are secured the laboratory will scan the model instead,
 A good quality stock tray can be used in to the impression copings, a soft tissue which could introduce the errors discussed
most cases, except when there is complicated replica in a flexible material (usually silicone) above. The scan is then used to mill a ceramic
anatomy and the fit of the stock tray is not is incorporated into the model and a stone or zirconia restoration (inlay/onlay, veneer,
accurate enough. In these cases, a custom- model is then poured. crown, bridge) which can subsequently be
made tray can be used instead.  Impression material and techniques are veneered with a pressed ceramic used for
 When carrying out the open tray (pick-up) very similar to conventional crown and bridge traditional crowns or bridges and customized/
impression technique, the tray is cut (Figure methods, as described above. Most clinicians stained (IPS e.max CAD and IPS e.maxZirCAD
10) and modified so that the impression use single consistency technique using a (Ivoclar-Vivadent), Procera (Noble Biocare),
coping guide pins pass through without polyether impression material. Atlantis (Astratech)). Ceramic glass blocks
September 2012 DentalUpdate 469
RestorativeDentistry

produce more aesthetic restorations than

zirconia. Zirconia restorations are, however,
stronger and more suitable for bridges.
In order to achieve a
predictable clinical outcome in construction
of fixed and removable prostheses,
the clinician needs to have a detailed
knowledge and understanding of the
impression materials and techniques
available.

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Figure 12. (a) Mind map flowchart outlining the decisions made in taking the primary impression in
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Louis: Mosby, 2004.

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CPD Answers
July/August 2012

1. D 6. A
2. C 7. A, C, D
3. C 8. C, D
4. A, B, D 9. A, B
Figure 12. (b) Mind map flowchart outlining the decisions made in taking the secondary impression in
an edentate mouth. 5. B, C 10. C

September 2012 DentalUpdate 471