Impression philosophies for completely edentulous patients

Impression philosophies for
completely edentulous patients
Dr. Amal Fathy Kaddah
Professor of Prosthodontic,
Faculty of Dentistry,
Cairo University

 Introduction and definitions
 Requirements and Objectives of Impression Making
 Knowledge of Basic anatomical landmarks.
 Knowledge and understanding of basic reliable techniques and
materials
 Skill and Patient management
 Impression techniques in normal or compromised situations
(Modified impression procedures)
 Bibliography.
Outline

First steps in making a denture
 Diagnosis and treatment plan
 Primary impression
 Diagnostic cast
 Custom tray
 Final impression
 Master cast

Principles of Impression Making
An ideal impression should provide:
 Maximum extension without muscle impingement.
 Intimate contact with the tissue area covered.
 Proper form of the borders including the posterior
border of the maxillary denture.
 Proper relief of hard and sensitive areas.
 To equalize forces on the denture foundation area.

Objectives of Impression Making
1) Preservation of remaining structures
2) Retention
3) Esthetics
4) Stability and Bracing
5) Support Carl O. Boucher in 1944
PRESS

1. Preservation of the alveolar ridges
Decrease pressure over the supporting structure
 Covering as much of the supporting areas as
possible within physiological limit.
 Minimize the possibility of soft tissue abuse and
bone resorption.

M.M. De Van’s dictum “It is more
important to preserve what
already exists than to replace
what is missing”.

2. Retention
 Intimate contact with the tissue area covered.
 Proper form of the borders including the posterior
border of the maxillary denture.

3. Esthetics
• Thickness of the denture flanges
• Thicker denture flanges are preferred in long-term
edentulous patients - labial fullness.
• Impression enhance Esthetics by perfectly
reproduce the width and height of the entire
sulcus for the proper fabrication of the flanges.

4. To be stable, a denture requires
• Good retention
• No interfering occlusion
• Proper tooth arrangement
• Proper form and contour of the polished surfaces
• Proper orientation of the occlusal plane
• Good control and coordination of the patient's
musculature.

5. Support
• The resistance to vertical forces of mastication
and to occlusal or other forces applied in a
direction toward the basal seat.
• Enhanced by selective placement of pressures
that are in harmony with the resiliency of the
tissues that make up the basal seat.

IMPRESSION
An impression is a negative record or imprint of the
tissues of the oral cavity that forms the basal seat
of the denture.
Reproduce a positive form and shape of the same oral tissues (Cast)
IMPRESSION TRAYS AND IMPRESSION TECHNIQUES

Final impressions
Final impressions are made using special
(custom or individual) trays constructed
specifically for each patient on the study
casts.
Definitive Impression

 According to the BSSPD guidelines: definitive
impression 'should record the entire
functional denture-bearing area to ensure
maximum support, retention and stability for
the denture during use'.
Definitive Impression

Custom Tray
 Individually made for each mouth
 Rigid and stable (Well adapted to the primary cast)
 Borders are slightly under-extended from the desired peripheral
extension, It should have 2 mm relief near the sulcus so that green
stick compound can be used to do border moulding.
 Frena should have adequate relief
 Tray and handle must not interfere with functional movements of
Rigid, Adapted, fitted and well extended
Ideal Requirements:

• It should be Dimensionally stable on the
cast and in the mouth.
• At least 2 mm thick in the palatal area
and lingual flange for adequate rigidity.
• Rigid even in thin sections and It should
not bind to the cast.
• The tissue surface should be free of
voids or projections.
• It should not react with the impression
material and Easy to removed.

Special or individual trays
1.Shellac base plates (Thermoplastic material)
2.Light-cure acrylic resin.
3.Auto polymerizing (Self curing) acrylic resin.
4.Cast or swaged metal.
5.Vacuum-form poly vinyl.
Types and Customized tray materials
Advantages of Special Trays
1 . Fit more accurately the individual arch of the patient.
2 . Bulk of the impression material is reduced.
3 . More accurate border contour
4 . Less impression material is used.
5 . More comfortable to the patient.

Shim or spacer
“ One thickness of modeling wax or
shellac base plate adapted on the
study cast under the special tray “
Advantages of Acrylic Resin Special Tray
Easily constructed.
More rigid than shellac trays.
Accept border tracing material.
Easily trimmed.
Closed fit special tray
Spaced special tray without stoper
Spaced special tray with stoper

Custom Trays
Spaced trays
Fitted trays
Windowed trays

Constructing the custom tray
1. Outline for the wax spacer is drawn on the cast
2. Posterior palatal seal area on the cast is not covered with
the wax spacer – maxilla
3. Buccal shelf not covered by wax – mandible why????
4. Baseplate wax approximately 1 mm in thickness is placed
on the cast
5. Self-curing acrylic resin tray material - uniformly adapted
over the cast
6. Tray thickness - 2 to 3 mm
7. Resin handle is attached in the anterior region of the tray

Outline for the wax spacer is
drawn on the cast
Outline the depth of vestibule
Provide room for frenal attachments

Scribe a blue line 2 mm above the red line.
The blue line determines the tray extension.
For the maxillary cast:

Relief areas and Block out undercut areas:
For the maxillary cast:
• Frenum
• Buccal surface of the tuberosity
• Labial undercut
• Rugae
• Flabby portions

For Mandibular cast:
Mark the vestibular region as previously described with red and
blue pencil.
Block out the undercuts.
• Lingual side of the
mandible opposite
the retromylohyoid
space
The usual areas that should be relieved are:
• Mylohyoid ridge
• Frenum  Buccal shelf not covered with wax

Wax Spacer
Provides room for impression
material
Do not place relief over blockout
Already space from tissue

Spacer design
Roy Mac Gregor recommends placement of a sheet
of metal foil in the region of incisive papilla and mid
palatine raphae

 Neill recommends
adaptation of 0.9 mm
casing wax all over
except PPS area
Boucher recommends
placement of 1 mm
base plate wax on the
cast except PPS area
Posterior palatal seal area on the cast is not
covered with the wax spacer

 Morrow, Rudd, Rhoads recommends to block out undercut areas with
wax, adapt full wax spacer 2 mm short of resin special tray border all
over & placement of 3 tissue stops equidistant from each other
 Sharry recommended Base plate wax adapted over whole area, four
stops 2mm width cut from wax : cuspid and molar region- extend from
palatal aspect of ridge: mucobuccal fold

Tray wax spacer remain in place during
border molding procedures

Space required for impression materials
Impression material Space required
Zinc oxide and Eugenol
Silicone (medium bodied)
Alginate
Silicone (heavy bodied)
Impression plaster
No spacer (0.5-1 mm)
1.5-3 mm (one layer of wax)
3 mm ( two layers of wax)
3- 4.5 mm (three layers of wax)
4.5 mm (three layers of wax)

When the wax blockout is complete soak the cast in water for
5 minutes. Then coat the surface of the cast with a separating
medium (a tin foil substitute or Petroleum jelly or Alcote)
Fabrication of Cold cure Acrylic – Dough Technique

1. Wet sandy stage, where the polymer is soaked in monomer.
2. Early stringy stage, where if the material is touched, fine
filaments are seen sticking to the finger.
3. Late stringy stage, where long strings are present.
4. Dough stage, In this stage, the material is very workable.
5. Rubbery stage, where the material cannot be manipulated any
more.
6. Stiff stage, The material loses its elasticity and becomes more
plastic. After the stiff stage, the polymerization is almost
complete.
Cold cure Acrylic –
Dough Technique

• Manipulation is done in the late stringy and the dough
stages. The material is kneaded in the hand, to achieve a
homogenous mix.
• Then the material is shaped into a 2 mm
thick sheet. Flattening the dough can be done using
a roller or a plaster mould or by pressing the material
between two glass slabs.
• Separating medium should be applied over the roller or the
glass slabs to avoid stickiness.

• The rolled sheet of acrylic is adapted over the cast from the center to the
periphery. This prevents the formation of wrinkles.
• The excess material should be cut out with a wax knife before the material
sets.
• The set material is then trimmed to obtain a smooth surface with smooth
margins

 Self-curing acrylic resin tray material- uniformly adapted over
the cast
 Tray thickness - 2 to 3 mm
 Resin handle is attached in the anterior region of the tray

1.Adapt the light-curing blank to the model, or over the wax spacer, taking care to
avoid thinning the material.
2.Trim the excess material with a wax knife to the required peripheral extension.
3.The material is cured by placing in an ultraviolet (UV) light box.
4.The curing process usually takes approximately 2 minutes; to ensure proper
setting the curing cycle repeated with the tray inverted and any wax removed.
5.The final extension can be ground using a tungsten carbide bur and
Light cure acrylic material

Border molding of the special tray
Performed with
 Thermoplastic modeling compound
 Waxes
 Impression materials

Shaping the borders of the tray
Borders of the impression are in harmony to the physiologic
action of the limiting anatomic structures

a- Sectional border molding
 Labially…….
 Posteriorly……
 Lingually……
b- One step border molding
Recording all borders
simultaneously

 A material that will allow simultaneous molding of all borders
has two general advantages:
1. The number of insertions of the tray for maxillary and
mandibular border molding is reduced.
2. Developing all borders simultaneously avoids propagation of
errors caused by a mistake in one section affecting the
border contours in another.
One- step border- molded tray:

Impression
Materials
Non-elastic
Elastic
Hydrocolloids
Rubber base
Polysulfide
Silicones
Polyether
Condensation
Addition
Agar (reversible)
Alginate (irreversible)
Plaster
Compound
Zinc Oxide and Eugenol
Waxes
Tissue conditioning

1. Dimensional accuracy: how easily the material reproduces the details of the patient’s mouth.
2. Dimensional stability: how long the material maintains accuracy after an impression is taken.
3. Hydrophilic properties: the ability to tolerate moisture and produce an accurate impression.
4. Wettability: how well the material flows into small areas.
5. Elastic recovery: ability to resist distortion once set and removed from the patient’s mouth.
6. Flexibility: ease of removal from the mouth after setting.
7. Tear strength: should resists tearing when removed, doesn’t cause patient’s discomfort during the process.
8. Biocompatible and hypoallergenic, non-toxic and have an acceptable odor and taste.
9. Has an inexpensive price.
10.Long working time, short setting time, and a long shelf life.
11.Disinfection should not reduce surface detail or accuracy
12.Could be poured multiple times, without losing accuracy.
An ideal impression material should have many features
Ashish R Jain* and Dhanraj M (2016) A Clinical
Review of Spacer Design for Conventional Complete
Denture. Biol Med (Aligarh)

As there is no impression material meets
all of the ideal requirements…
There is no best material for making
impressions, but there is the best
material you use to achieve the best
results

The basic differences in techniques for final
impressions can be resolved as those that
record the soft tissues in a functional position
and those that record the soft tissues in the
undisplaced or rest position.
FINAL IMPRESSION TECHNIQUES OR THEORIES

Preliminary impression materials :
 Impression compound
 Alginate
 Putty
Final impression materials:
 Plaster of Paris,
 Zinc Oxide-eugenol Paste,
 Irreversible Hydrocolloid,
 Silicone, Polysulfide Rubber, Polyether,
 Tissue-conditioning material
Impression techniques may be classified Depending on
the purpose of the impression

51
Diagnostic Impression
 The negative replica of the oral tissues used to prepare a
diagnostic cast.
 Used for study purposes like measuring the undercuts, locating
the path of insertion.
 Is made as a part of treatment plan and to estimate the amount
of pre-prosthetic surgery.
 Articulate the casts on tentative jaw relation and evaluate the
inter-arch space.

Impression techniques may be classified depending on:
Amount of pressure used
1. Pressure technique
2. Minimal pressure technique
3. Selective pressure technique
Based on the position of the mouth while making
impression
1. Open mouth
2. Close mouth
Based on the method of manipulation for border
molding.
1. Hand manipulation
2. Functional movements

Open mouth technique
Made with tray held by dentist and mouth open
Muscle movements may be emphasized and can be seen
by the operator
The rationale behind this technique is that the supporting
tissues are recorded in a functional relationship.
Requires occlusal rims to be made for closed mouth
technique
Closed mouth technique
Impression techniques may be classified depending on the position
of the mouth while making impression

Hand manipulation
Dentist uses hand manipulation for
movements of lips and cheeks
Functional movements
Patient makes functional movements such
as sucking, swallowing, licking or grinning.
Impression techniques may be classified depending on the
method of manipulation for border molding

Elastic
1. Reversible hydrocolloid
2. Irreversible hydrocolloid (Alginate )
3. Rubber impression materials
a. Polyether
b. Silicone
Non-elastic
1. Gypsum products (Plaster of Paris)
2. Metallic oxide pastes (Zinc Oxide/ Eugenol)
3. Impression compound
Depending on the material used

I. Minimal pressure impression technique (Mucostatic
impressions or open mouth impression)
II. Mucofunctional (Mucocompression or Pressure
Impression Technique).
III. Selective pressure impression technique.
IV. Functional Mandibular Impression.
V. Other alternative techniques.
Classification of Final impressions theories
and techniques

The techniques for final impressions
differ according to
 Construction of The trays
 The impression material used
 The way of impression making

How is pressure controlled?
Spacer
Perforations
Material viscosity

Relationship of the wax relief and the
various impression techniques
 The thickness and position of the wax relief
in a custom tray allows the dentist to
control how much and where pressure is
placed during the impression.

 The soft tissues are not compressed nor distorted
 The impression material must flow readily
 Trays constructed for this technique require a spacer with
stopers and one or two holes to allow escape of the material
 Plaster of Paris was the only true mucostatic impression
material though the hydrocolloids often give equally good
clinical results.
I. Minimal pressure impression technique
(Mucostatic impressions (open mouth impression)

 Soft tissues that are displaced during function will
attempt to return to the undisplaced position when
the forces are released.
 The dentures will be unseated from their bases by
this tissue action. ( tissue rebound)

The mucostatic technique Results in a
denture, which is closely adapted to the
mucosa of the denture-bearing area but has
poor peripheral seal.
•Retention is mainly due to interfacial surface
tension.

Advantages:
1. The operator can see and insure proper border molding and
muscle movements are more easily accomplished.
2. There is less distortion to the mucosa. High regard for
tissue health and preservation: better prognosis
3. It is the technique of choice for flabby and thin wiry
ridges.

Disadvantages:
1. The mucosal topography is not static over a 24-hour
period.
2. The lack of border molding reduces effective peripheral
seal and reducing retention as well as food slip beneath
the denture.
3. The short denture borders, The short flanges may reduce
support for the face which can affect esthetics.
4. The shorter flange would mean less lateral stability.

Technique
Primary impression is made with Alginate.
A baseplate wax space is adapted.
A special tray is adapted over the wax spacer.
Escape holes are made for relief.
Spacer is removed and an impression is made with a free
flowing material.

 This theory was proposed by Greene in
1896, on the assumption that tissues
recorded under functional pressure
provided better support and retention
for the denture.
II. Mucofunctional or Mucocompression impressions:
A- Closed mouth impression technique

 Records tissues in their functional/supporting form
 All tissues are recorded under equal pressure
irrespective of their anatomy
 Mechanical rather than biological

 The impression material most commonly used for
this technique is zinc oxide and eugenol paste.
 Trays require occlusion blocks set at the required
vertical dimension.

Primary impression is made with impression compound.
Using Special tray with bite rims, with uniform occlusal surfaces
and adjusted vertical dimension. (Why ???)
Secondary Impression is made using Zinc Oxide and Eugenol
impression material.
The impression is inserted in mouth and held under biting
pressure for one or two minutes.
Borders are molded by asking the patient to perform
functional movements while biting (close) on the wax rims.
Technique

Border Mold
Accurate Registration
of Peripheries for
Retention
Study cast

Advantages:
1. Better retention and support
2. The patient can exert his own
masticatory force on the impression
material Stable during function

Disadvantages of the theory
1. Excess pressure could lead to increase alveolar bone
resorption.
2. Excess pressure on peripheral tissues and the palate
interferes with blood supply leads to transient
ischemia, and this may accelerate ridge resorption.
3. Pressure applied during making the impression is not
identical to functional load

4. Dentures constructed from such an impression do
not fit well at rest, as the compressed tissues
rebound when the tissues resume their normal
resting state.
5. Pressure on sharp bony ridges results in pain.
6. An overextended denture may result due to
improper border molding.

B- Opened mouth impression technique

Metallic oxide paste (Zinc oxide/Eugenol impression paste),
green stick impression compound. (close fitting tray)

When tissues are held in a displaced
position, the pressure limits the normal
blood flow.
When normal tissues are deprived of
their blood supply, the result is
resorption.

 First Advocated by Boucher in 1950 This technique combines the
principles of both pressure over areas and minimal pressure on
others technique.
 The tray is constructed with relief over sensitive areas and
closely adapted over stress bearing areas.
Applied aspect
III-Selective pressure impression

 Boucher divided basal seat area into different zones
according to capacity to withstand masticatory loads
without undergoing resorption.
Primary
stress
bearing area
Relief areas
Secondary
stress
bearing area

1. The plaster wash impression. (Oldest )
2. Modified impression procedures for perceived ridge
support problems:
i. Displaceable (flabby) anterior maxillary ridge.
ii. Fibrous (unemployed) posterior mandibular ridge.
iii. Flat (atrophic) mandibular ridge covered with
atrophic mucosa.
3. The light body wash selective pressure impression
technique.

1. The plaster wash impression. (Old )
2. Modified impression procedures for perceived support problems:
i. Displaceable (flabby) anterior maxillary ridge
1. Window tray impression technique using zinc oxide imp. material
2. Window tray impression technique using polysulfide and zinc oxide imp.
material
3. Window tray impression technique using a medium-bonded PVS imp.
material and light-bonded PVS imp. material
ii. Fibrous (unemployed) posterior mandibular ridge
iii. Flat (atrophic) mandibular ridge covered with atrophic mucosa.
3. The light body wash selective pressure impression technique.

 The techniques consider the physiologic functions
of the tissues of the basal seat, and therefore
appears more sound and appealing.
 This theory is based on a thorough understanding
of the anatomy and physiology of basal seat and
surrounding areas.

It is the oldest technique of the selective pressure
impression technique:
1- Compound impression
2- Scraping the compound to make a room for
the impression material
3- Plaster wash impression
I. The plaster wash impression

2- Modified impression procedures because of
perceived support problems
i. Displaceable (flabby) anterior maxillary ridge
ii. Fibrous (unemployed) posterior mandibular
ridge
iii.Flat (atrophic) mandibular ridge covered with
atrophic mucosa.

i. Displaceable (Flabby)
Anterior Maxillary Ridge
2- Modified impression techniques for
perceived ridge support problems

Support Problems May Be
Overcome By
 Appropriate relief of the master cast.
 Modified impression techniques.

A close fitting tray is constructed in cold-curing acrylic resin and
designed so that flabby area of the ridge is uncovered.
1. Window Tray Impression Technique using zinc oxide imp. material
This technique is used if the flabby tissue is in the anterior part of the mouth.
i. Displaceable (Flabby) Anterior Maxillary Ridge

Window Tray Impression Technique
1) Outline the mobile tissue on your
preliminary cast.
2) Construct the custom tray so that
there is a window (open area) over
the mobile tissue.
3) The handle should be placed in the
middle of the palate.
4) Border mold and make the zinc oxide
impression in the usual manner.

5) Cut out the zinc oxide impression material in the
window with a sharp scalpel.

7- Completed Impression
6) The mobile tissue area will be recorded
with a plaster of Paris impression
material while the impression is seated in
the patient’s mouth, with a small brush or
syringe.

 Mobile tissues are most often seen anteriorly and may be
particularly prominent in patients with combination syndrome. It
is inadvisable to remove these mobile tissues because the
underlying bony ridge is usually knife edged. These tissues act as
a cushion and rarely impinge upon the interocclusal space.
2. Window Tray Impression Technique using polysulfide impression
• This technique is used to record highly
mobile or hypertrophic tissue with
minimum displacement.

1. Outline the mobile tissue on your preliminary cast.
2. Construct the custom tray so that there is a window (open area) over
the mobile tissue.
3. The handle should be place in the middle of the palate
4. Border mold and make the polysulfide impression in the usual manner

 Cut out the polysulfide impression material
in the window with a sharp scalpel.
The mobile tissue area will be
recorded with a zinc oxide
impression material (Krex).

Completed Impression
Master cast
 Seat the impression back into the patient’s mouth.
 Mix the Zinc Oxide (Krex) impression material and
apply it over the mobile tissue with a small brush or
syringe
 Master cast

Displaceable area removed from special tray. In this case, a medium-
bonded PVS impression was used.
b) Completed impression. Here a light bodied PVS impression material
was syringed onto the displaceable tissue
3. Window Tray Impression Technique using , a medium-bonded
PVS impression a light bodied PVS impression material

Demerits
 Some feel that It is impossible to record areas
with varying pressure.
 Some areas still recorded under functional load,
the dentures still faces the potential danger of
rebounding and loosing retention.

2- Modified impression techniques
ii. Fibrous (Unemployed)
Posterior Mandibular Ridge

This ridge as such is not
useful for support
This condition may be
recognized by the presence of
a thin, mobile thread-like ridge
which is essentially fibrous in
nature
ii. Fibrous (Unemployed) Posterior
Mandibular Ridge

a-c Staged sequence of techniques:
a) Preliminary stage an impression of the denture-bearing area
recorded using tracing compound.
b) Crestal area cleared of tracing compound - tray perforated on
crestal area;

 Inject some light-bodied PVS onto the buccal and
lingual shelves of the greenstick and gently insert
the impression.
 Excess material will be extruded through the
perforations, and the fibrous ridge will assume a
resting central position, having been subjected to
even buccal and lingual pressures.
 The impression is now treated as for a
conventionally made impression.

c) Definitive impression using light-bodied
polyvinyl siloxane

2- Modified impression techniques
iii. Flat (atrophic) mandibular ridge
covered with atrophic mucosa
(Atwood's ridge )

View of atrophic mandibular ridge suitable for
admix impression material
atrophic mucosa (Atwood's ridge )

Selective pressure impression techniques
Complicated by folds of atrophic
and/or non-keratinised tissue
lying on the ridge.
A viscous admix of impression
compound and tracing compound
removes any soft tissue folds and
smoothes them over the mandibular bone; this reduces the
potential for discomfort arising from the 'atrophic sandwich’,
i.e. the creased mucosa lying between the denture base and
the mandibular bone.
 .
 .

 An Admix of 3 parts by weight of (red)
impression compound to 7 parts by weight of
greenstick; the admix is created by placing the
constituents into hot water and kneading with
vaselined, gloved fingers.

1. The plaster wash impression. (Oldest )
2. Modified impression procedures for perceived ridge
support problems:
i. Displaceable (flabby) anterior maxillary ridge.
ii. Fibrous (unemployed) posterior mandibular ridge.
atrophic mucosa.
3. The light body wash selective pressure impression
technique (conventional technique).

 One of the most conventional method used.
 They attempt to record the tissues at rest. The only
exception is the posterior palatal seal area
3. The light body wash selective pressure imp. Tech.
 Impression with a light
body material to achieve a
final impression.
Beumer et al (2011)

The selective pressure technique
 This selective pressure technique is a combination of
extension for maximum coverage within tissue tolerance
with light pressure or intimate contact with the movable,
loosely attached tissues in the vestibules. The impression
is refined
with minimum pressure
utilizing a wash of light
body impression

Final impression Instruments and materials (Armamentarium)
•Preliminary casts with final impression trays
•Patient's chart.
•Gloves, mask, Mouth mirror
•Green Stick compound.
•Water bath heated to 60 degrees C.
•Hanau torch.
• Slow speed Straight handpiece and Carbide acrylic burs and stones.
•Gauze sponges - 2X2.”
• Scalpel.
• wax Spatula.
•Vaseline.
•Indelible marking sticks or pencil.
•Material used (zinc oxide and eugenol Paste or rubber base imp. Mat.)

Clinical procedures: preparation before the
patient arrives
1. Properly disinfect the assigned operatory and obtain
starting check.
2. Set up your unit on clinic before the patient is due.
3. Have all instruments and materials ready before
patient's arrival.
4. Ensure you have a torch and a water bath - set
temperature at 58 degrees.
5. Seat the patient in an upright position and protect the
patient's clothing with a napkin

Steps of Impression making
 Examination and conditioning of the patient and the mouth.
 Seating of the patient
 Selection of impression material
 Selection of the impression tray
 Making the preliminary impression
 Constructing the primary cast
 Selection of impression technique
 Fabricating the custom tray
 Border molding
 Making the final impression

Maxillary and Mandibular Preliminary impression
 Border moulding
 Labial and buccal vestibules
 Coronoid process
 Impression poured - stone
 Posterior extent of tray – retromolar pad
 Tray loaded with material and catered over the ridge
with tongue slightly raised
 Alternating pressure on molar region with index finger
 Functional movements done to get the border limit.

Checklist for Maxillary Final Impression Tray
1. Extend to junction of hard and soft
palate (vibrating line)
2. Extend into pterygomaxillary
notches (hamular notches)
3. Cover maxillary tuberosities
4. Extend into buccal and labial
vestibules.
5. Provide relief for labial and buccal frena.
6. Be neat, clean and free of sharp or rough areas

Areas requiring special attention:
 Posterior palatal seal area
 Incisive papilla
 Buccal and labial vestibule
 Mobile, hypertrophic tissue
 Palatal torus

Post. Vibrating line,
Hamular notch
The tray must extend 2-3mm
beyond the vibrating line
2 mm beyond fovea palatinae

Curvature of the soft palate
III
II
I
Class I  Gentle Curvature
Class II  Medium Curvature
Class III  Abrupt Curvature

 The posterior palatal seal area an area that lies between the anterior and posterior
vibrating lines “Ah” line: saying “ah” will cause the soft palate to lift. It is found to be
very effective in locating the posterior vibrating line.
 Blow-line (valsalva maneuver): an accurate method for locating the anterior vibrating line
which freely moves when the patient attempts to blow through the nose when it is
squeezed tightly. The blow-line a close approximation to the junction of the hard and soft
palate. Cohesion, adhesion, and interfacial surface tension have limited value unless an
intact peripheral seal is present.

RELIEF WAX of the Preliminary maxillary Casts. Base
plate wax should be added to provide relief over median
palatine raphe and flabby areas undercuts
Only slight wax blockout of undercuts
to allow for consistent and
repeatable seating

• Well adapted acrylic tray 2-3mm thickness.
• Border extensions should be 2-3mm short of
the depth of the vestibule when the intraoral
tissues are at rest .
• Handle design should not impinge on the
vestibule nor distort the lips .
• Finger rests in the 1st molar and 2nd premolar
region so the fingers should not distort the
vestibule when border molding and making the
mandibular master impression.

Seating of the patient Position of the operator
for maxillary impression
Position of the operator
for mandibular impression
Patient
mouth
Elbow
of the
dentist

1. Patient seated, head against head rest, mouth
open and relaxed.
 If patient opens wide commissures constrict,
limiting access

2- Place the maxillary tray in the patient's mouth by rotating
into place. Retain it with the index finger of one hand in the
palatal portion of the tray. Gently reflect the lips outward
and downward. Look carefully for overextension and under-
extension of borders along the labial and buccal vestibule.

3. Check The tray adaptation and extension to be
2-3 mm short of the frenum and the depth of
the vestibules.

4. Identify overextended borders by looking for sulcus
displacement and blanching. Trim or relieve the
tray borders with suitable burs
Grind till the marked line with the carbide bur
immerse in water to clean it up

5. Ensure that the tray has the correct extension. The tray
should be 2 mm short of the reflections (from the base of
the sulcus as seen when the cheek lifted by the fingers)

6- Mark the posterior peripheral seal area and the fovea Palatina
with indelible pencil. Detect the overextension and Grind till the
marked line with the carbide bur

The vibrating line can be located by blowing out through the nose
with closed nostrils so that the soft palate expands downwards.
The posterior border of the tray should he trim-
med to about 2 mm beyond the vibrating line

Border molding of the acrylic
maxillary custom tray

Slowly Soften the modeling compound over
a flame
Border molding is performed using either
the softened green or red compound

Remember that you have to
Dry the tray before every time you
put the molding material

Heating Compound
• Best to use Bunsen Burner
not Hanau Torch
• Warm until it starts to droop
• Do not overheat – if catches
fire or boils, it will not mold
properly

Dry the tray, Heat the modeling compound over a flame,
Slowly soften the end of the compound, Dry the tray and
then add the compound to distobuccal area (A).
Compound Application (A)

 Apply over periphery of tray on the distobuccal
area (A), in a thickness just slightly narrower
than the compound stick

Re-soften after application
 Flame with a hand torch until all seams, irregular or
sharp contours have disappeared.

Tempering Compound
 Temper in a water bath (135-140°F) for several seconds
 Prevent burning.
 Hot water bath will keep compound soft for an extended
period.

The temperature varies depending on the type of
compound used

Seating the Tray
Seat the tray firmly in mid –palatal area
during border molding procedures
 Centralization
 Pressure
 Molding

The distobuccal area is molded by instructing the
patient to move the mandible laterally and
anteriorly, pucker (pull together) and smile.

Ask the patient to slightly close and
move the mandible bilaterally
Support the compound from sagging
and Rinse in tap water and dry again

Trimming the compound: The compound must
be thoroughly cooled before you begin trimming.
Otherwise the compound will be easily distorted
Excess compound on
the external surfaces
is best removed with a
fresh, sharp scalpel
blade.

Insert the tray with compound being careful to
retract the cheek with a mouth mirror or your
index finger to mold the buccal area (B).
Compound Application (B)

Carefully trim away the compound
that has flowed into the inner
surface of the tray. Failure to do
so will result in an impression
that displaces tissues
inappropriately.
Use a red handled knife or
Kingsley scraper to remove the
compound that flowed into the
inside of the tray.

This area is excessively
thick. This is a common area
of overextension. This area
needs to be further
remolded.
Overextension
The compound is reheated
with the alcohol torch,
retempered in the water bath
and further refined intraorally.

Note that the denture
extension after it has
been refined in this
area is thinner and
flatter.
What structure limits the thickness and
length of the denture border in this region?
Coronoid Process.

Note the difference Before After

The anterior areas of the labial flange (C)are molded by:
- Massage the upper lip with a lateral motion,
- Instruct the patient to pucker and smile
- Check the flange thickness for proper lip support

Don’t pull down on the lip strongly
This maneuver will foreshorten the denture flange

Labial Frenum
Labial Frenum should be narrow
Buccal frena usually broader.
“V- Shaped”

Developing the Posterior Palatal Seal (D)
Place 2-3 mm of compound on top of the tray in a
butterfly configuration to displace the tissues in the
posterior palatal seal area.

Developing the Posterior Palatal Seal- Area
 Seat the tray firmly.
After the tray has been
in position for 10
seconds ask the patient
to swallow. Remove the
tray and chill.

Trim compound in posterior palatal seal area
 This patient presents with a small maxillary torus
and the compound has flowed onto the surfaces of
the tray that cover it. Remove the compound so as to
eliminate heavy contact in this region.

Testing Peripheral Seal and retention

 Pull on the tray handle to test retention. If
retention is lacking check the following:
1) Check buccal pouch, hamular notch and posterior
palatal seal area
2) Check the length and thickness
of the denture extensions

If the retention is adequate you are ready
to cut back (scraping) the compound.

Retention is now acceptable, With the edge of knife blade
scrape away a thin layer of compound from the border
molded periphery. This will create space for your impression
material and avoid undesirable tissue displacement.
The areas of the periphery overlying the frenum should be
relieved more aggressively.

What is the purpose of the vent hole?
1. To relieve the pressure over the incisive papilla and the
rugae.
2.To prevent entrapment of air bubbles in the impression.
Caution: Do not drill the palatal
relief hole(s) in the maxillary tray
until are borders have been
molded and the peripheral seal
demonstrated.

Apply a thin layer of tray adhesive and permit it to
dry. Note that adhesive is applied 2-3 mm onto the
external border of the tray.

An elastic, free flowing, light body polysulfide
impression material for most maxillary
impressions. The material should have
hydrophilic properties and adequate viscosity to
reduce the probability of gagging.

 Measure out equal lengths not equal amounts of
polysulfide impression material.
 Keep the strips of material widely separated so they do
not flow into contact and set prematurely.
 Tape your mixing pad close to the edge
of the counter. A stable, immobile
mixing pad will make it easier to mix the
material.
 Use the tapered blade spatula as shown.

Key factors for a successful impression:
 Begin mixing with the tip of your spatula.
 Attempt to confine the impression
material to a small area of the pad.

Finish mixing the polysulfide
material with the flat edge of the
blade. This technique will
minimize the number of air
bubbles incorporated into the
material.
Apply a thin layer of impression
material to the tray with a
cement spatula.

material and that all surfaces are
coated.
. The tray is coated with a thin layer of impression
material.
. Close inspection reveals that there are no bubbles
associated with the impression

Retract the lips with your index finger or mouth
mirror and seat the tray.
*Be sure to drape the patient before making the final impression.
Polysulfide material cannot be removed and permanently stains clothing.

Seat the loaded impression tray in pt.’s mouth
and go through the same soft tissue
manipulation process as during border molding.

Labial Frenum
1- Raise the lip outward and downward
and line the tray up to the frenum,
Do not pull to one side

2. Firmly seat the tray and allow the impression
material to flow.
3. Use the mouth mirror to remove excess material
that may be flowing down the pts. throat.

8. Instruct the patient to breath deeply through their nose and
tilt their head forward.
4. Massage face..
5. Pucker lips..
6. Smile ..
7. Move jaw side to side .

9. Hold the tray in position until the impression
material is set. Light body polysulfide impression
material requires 7-8 minutes to polymerize.

10. Remove the impression and Examine it
carefully. What factors make for a good
impression?
Completed Maxillary
Impression

1. Smooth well defined peripheries.
2. Maximum extension
3. Even pressure distribution (there should be no areas
where the underlying tray or compound shows through)
4. There should be intimate tissue contact

Trim the excess unsupported impression material.
Spray the impression with the appropriate
disinfectant
Trim and Disinfect the Impression

Completed Maxillary Impression
Impression is now ready to be boxed.
Remember, the impression must be poured
within 1 hour to avoid distortion.

Inspect the impression for voids
or bubbles
Box impression and pour master
cast
Final Impressions: Boxing & Pouring

Box Impression
Stronger cast with peripheries for Processing

MASTER CASTS
ADVANTAGES OF BOXING
1. The border of the impression are preserved.
2. The thickness of the base of the cast
can be controlled.
3. Permit vibrating the stone material
into the impression.
4. Time is conserved.
5. Material are conserved

1. Extend to external oblique ridge.
2. Extend into retromylohyoid space.
3. Extend into alveololingual sulcus.
4. Be neat, clean and free of sharp
areas.
Checklist for the Mandibular Final
Impression Tray

The outline for the custom tray should be drawn 2-3 mm short of the
denture outline. sharp edges,
b, Baseplate wax should be added to provide relief over tori, and
flabby ridges, undercuts of the anterior labial and posterior lingual
regions should be blocked out with wax.
Note the finger rests and the size and
position of the handle.

Block out the undercuts.
• Lingual side of the mandible opposite the
retromylohyoid space
The usual areas that
should be relieved are:
• Mylohyoid ridge
• Frenum
Buccal shelf not covered with wax

Outline of the retromolar pad and the buccal
shelf bone with an indelible pencil.

The tray should be inserted into the mouth
and evaluated by manipulating the lip.

The extension should be 2-3 mm short of the frenum
and the depth of the vestibules.

The denture border can be extended 1-2
mm beyond the external oblique ridge.

Outline the retromolar pad with an indelible pencil,
Check to ensure that the tray properly extends
onto the pad and does not impinge upon the
masseter groove.

The border of this tray comes in contact with the
floor of the mouth in the sublingual gland area. It
is somewhat overextended. b, The lingual border
of the tray requires few corrections.

When the tray is appropriately adjusted, it
will not be raised in the mouth and will
remain in place

Dry the tray. Slowly heat the compound and
apply to area this on one side of the tray.
avoid placing the compound onto the pad area
inside the tray
Mandibular Sequence of Border Molding

Always temper the compound in the water bath for
5 seconds before placing the heated compound in
the mouth. The water bath should be set at 110
degrees when using low fusing compound.

The compound should be added continuously on the
buccal border anterior to the retromolar pad.
It should be extended somewhat beyond the
external oblique ridge while its irregularities
are corrected with the fingers

-Insert the tray with compound being careful to retract
the cheek with a mouth mirror or your index finger.
-Be careful to seat the tray evenly.
-Define the tray extension by molding the lateral
border(A) by massaging the cheek and having the pt.
pucker and smile.

-Remove tray from the mouth and chill the compound
-Trim the excess compound that has flowed onto the
tissue surface or the external surfaces.
-This is done with care using a red handled knife.

Completed Buccal Flange on one side is
complete. This defines the proper tray
extension for this area.

Add compound to distobuccal area (B)
(buccinator insertion, masseter groove
region and area defining the posterior
border associated with the retromolar pad).
Border molding the posterior flange-area (B)

Temper, carefully rotate the tray into the
mouth, and ask the patient to close while
holding the tray in position, resisting the
closure with your forefingers on the finger
rests.

The effect of the masseter muscle has been
registered at the distobuccal border.
Active contraction creates a concavity and less
active contraction leads to a convex border.

Masseter Muscle influencing area
Distobuccal extension, patient closes against force,
activates the masseter, which will displace the compound

X X X
Support the mandible
with the thumbs

Border molding the labial flange-Area “C”
Apply compound to area “C”.

-Temper, insert and gently massage the lower lip.
-Don’t pull up the lip as it will shorten the labial
vestibule, leading to a decrease in the peripheral seal.

Compound should be added onto the border until it
comes in contact with the mucosa of the floor of the
mouth. Thus, the peripheral seal is completed
Border molding the lingual flange (D)

• Temper, insert and mold area lingual
area by instructing the patient to push
their tongue against your thumb placed
in the lower incisor area.
• Proper extension will create seal for the
mandibular denture in selected patients
with favorable tongue position and floor
of mouth posture.
Border molding the lingual flange (D)

Add compound to this area Temper, insert and mold by
instructing the patient to push their tongue against your thumb
placed in the lower incisor area and to swallow . It may take
several applications to properly define the length and contour of
the denture border in this area.
Border molding the lingual flange (E)

-Exaggerated tongue movements to record the
myloyoid muscle during impression taking should
be avoided.
-The patient is instructed to slightly touch the corner of the
mouth with the tongue

The lingual border is then molded. Border molding of the
mylohyoid ridge area should be performed 4-6 mm below this
ridge. Later the impression surface of the denture on
the mylohyoid ridge area is relieved

The borders of the border-molded tray should be
smooth and rounded. The notches for the frenum are
definite and adequate clearance is provided for the
lingual frenum

Scrape back the border
Scrape the impression compound .5 mm in width
and height to provide space for the impression
material

After the compound is cut back apply a thin layer of
polysulfide tray adhesive to the surface of the tray. Be
sure to apply the adhesive 3-4 mm beyond the border.
Apply Tray Adhesive

Mix polysulfide as directed and apply a thin
layer of impression material to the tray.
Do not overload the tray (just painting).
Mandibular Impression

Instruct the patient to lift their tongue. Insert and seat the
tray and begin border molding. Continue border molding
until the material begins to polymerize.
Do not let go of the tray. Hold the tray in position until the
material has polymerized.

Following polymerization (7-8 minutes),
retract the lip to break the seal and gently
remove the tray.

Rinse, disinfect, and carefully inspect
the impression. Remove flash with a
sharp scissors

Inspect the impression to determine
if it is acceptable

1. Smooth well defined peripheries
2. Maximum extension
3. Even pressure distribution (there should
be no areas where the underlying tray
or compound shows through)
4. There should be intimate tissue contact
What factors make for a good
impression?

Two variations are commonly used
for functional impressions.
(A) Local areas of modification
(B) Problems associated with denture
space/neutral zone
IV- Functional Mandibular Impression

(A) Local areas of modification
Dentures may exhibit
looseness, not arising
primarily from retention
problems but because of
localized areas of poor
functional adaptation
Functional impression using a chairside resilient lining material

Chair side Reline
•Reline material: Pink/white
•Apply Vaseline (very slight coating)
•Mix according to instructions

 Seat reline impression
 Check on extensions and patient
border mold
 Have patient close teeth in CR
gently!! 7-10 min after functional
molding the periphery
 Remove denture from mouth
 Trim the tissue conditioning
material

 Evaluate peripheral roll
 Can add on, or grind
 Functional impression technique:
Tissue surface adaptation

Reline and rebase techniques (including
secondary template impressions)
Addition of Material to the tissue side of a denture to
improve its adaptation to the supporting mucosa
This impression technique is performed in
an old denture
Reline

C D Reline
Check extensions Indicate amount of peripheral
reduction required
Border Reduction Peripheral reduction + Tissue surface

• With teeth in contact in centric relation, carry out border
molding procedures
• Allow denture to remain in mouth until material sets (7-10
min)
• Check on extensions and patient border mold

Border Molding Completed Palatal surface vented after B. M. Border molding completed
C D Reline
ZnO wash.
Posterior palatal
seal area using
impression wax
Trim excess wax
beyond anterior line
Reline final
impression

In the case of the maxillary impression, there is
also merit in perforating the palate in the midline
of the rugae to prevent any possibility of
imperfections in the impression
Wash comes through vents

1. Reduce periphery 1-2 mm
2. Relieve undercuts
3. Mix tissue conditioner according to instructions
4. Spread uniform layer over surface of denture
5. Insert and have patient close in centric relation
6. With teeth in light contact, carry out border molding
procedures
7. Allow denture to remain in mouth until material looses
its tackiness (7-10 min)
Procedures of the Functional impression Procedure

Indications for Functional
impression technique
 Geriatric patient
 Medically compromised patient
 Lack of retention: New denture
 Reasonably good occlusion

Tissue Recovery Program
1. Removal of the prosthesis at night
2. Initiation of oral hygiene measures: rinses, brushing,
bubble gum
3. Location and removal of acrylic base pressure areas.
4. Correction of base extensions
5. Correction of occlusal disharmony
6. Use of a resilient tissue conditioner.

Indications of denture space/neutral zone
It is designed for patients with
 Poor track records of (lower) denture
stability.
 A large tongue or other anatomical
anomaly.
B- Problems associated with
denture space/neutral zone

Dynamic impression technique
Cagna et al, The neutral zone revisited: From historical concepts to
modern application,
J Prosthet Dent 2009;101:405-412

•The stops must contact the upper teeth at the selected OVD.
 The upper denture is set up
conventionally to the
prescribed occlusal vertical
dimension (OVD).
 Opposing the upper set-up is a
resin base with three vertical
stops joined by a wire bent in
a sinusoidal manner

These exercises provide an indication of
where inward-directed forces from the
buccinator muscles are equalled or
'neutralised' by outwardly-directed lingual
forces ie the zone of minimal conflict
Polyvinylsiloxane putty is added to
the conventional fitting surface
and also to the buccal and lingual
aspects of the lower base which
has been coated with the requisite
adhesive, and placed in the
patient's mouth. the upper try-in is
inserted and the patient asked to
close to the OVD, swallow and
carry out closed mouth exercises.
Completed functional impression of
denture form - recorded in PVS putty

These enable an exact wax form to be poured to give a
functional form to the polished surfaces and occlusal form of
the lower denture.
Setting of the lower teeth to match with the functional template
Plaster or laboratory-putty keys
made of the functional
impression to give A functional
form to the polished surfaces
and occlusal form of the lower
denture.

Making the impressions using different
materials have the same soft tissue
manipulation process as that for the previous
technique.
V- Alternate Final impression Techniques for
Complete denture construction

The material should have
hydrophilic properties and
adequate viscosity to reduce
the probability of gagging

Impression Materials either
Light body Polysulfide Rubber Base Material
Border molding by green Stick compound Or Medium body
Rubber Base Material
Zinc Oxide and Eugenol
Border molding by green Stick compound.
Polyvinylsiloxane impression materials such
Border molding by a heavy body and a wash impression is
then made with the monophase material.

1- Rubber base impression material with border
molding using Elastomeric impression material
Medium body type elastomeric impression
material along the periphery of the tray.
Heavy body type elastomeric impression
material along the periphery of the tray.
The elastomeric impression material which
flowed inside the tray should be removed
The final maxillary impression is completed with
light bodied type elastomeric impression material

2. Zinc Oxide Final Impression
 The fully customized trays should exhibit good retention, a
matter of confidence for both clinician and patient.
 Perforation of the upper tray may be done at the chairside,
to enhance retention of, e.g. irreversible hydrocolloid and/or
to prevent the occurrence of air bubbles being present in the
palatal vault.

Tray wax spacer remain in place during border molding
procedures. Remove Tray Spacer and Load Impression Material

 Stick modeling compound is added in sections to
the shortened borders of the resin tray and molded
to a form that will be in harmony with the
physiologic action of the limiting anatomic
structures.
 The final impression material is mixed according to
manufacturer’s directions and uniformly distributed
within the tray.

3- Alternate Technique- Virtual PVS
Polyvinylsiloxane impression material
 The heavy body and
monophase materials are
recommended.
 Paint the tray with a thin
layer of adhesive

III- Alternate Technique- Virtual PVS
 Border molding of the tray is
accomplished with the heavy
body material.
 A wash impression is then
made with the monophase
material.

Check the final impression for clinical
acceptability
- Flange extensions -soft tissue detail
- Posterior palatal seal hamular notch
 Gently massage the patient’s lips
and cheeks.
 After 1 min. have the patient
gently pucker, smile and move
their jaw side-to-side, forward and
back.

Examination and conditioning of the
patient and the mouth before starting
 Inflammation of the mucosa
 Distortion of denture-foundation tissues
 Excessive amounts of hyperplastic tissue
 Insufficient space between the upper and lower
ridges

Stub handles will not distort the lower
lip; any distortion is likely to alter
sulcular form of the definitive impression

Your finger is too close to the tray border
(not even touching it), then the impression
material will flow around your finger, making
a circular and obviously incorrect impression.
Note imprint where fingers
were placed to seat the tray.
Note small white pointer showing
area of distortion on right
distobuccal border.

The additional acrylic on the
right side strengthens the tray
and "lifts" the finger away
from the tray borders
preventing it from becoming
part of the denture impression.
Prevent breakage by adding a spine of acrylic
along the crest of the ridge, extending the spine
right to the handle.

Rubber base is 5mm thick preventing
the borders from reaching the fold.
 Do Not perforating the customized trays for
complete dentures prior to establishing a
peripheral seal.
 Similarly, in order that the form of upper
and lower labial sulci are not
overextended, there is merit in having stub
handles that will not distort the lips

Tray wax spacer remain in place during border
molding procedures
Add compound across
the top of the tray (not
at the edge)

The choice of material,
within reason, is of
secondary importance.

ZnO
With Rubber Base Reline
with PVS plaster Template
Alginate

 Beumer John III, DDS, MS, Robert Duell, DDS and Eleni Roumanas: Final Impressions; Division of Advanced
Prosthodontics, Biomaterials and Hospital Dentistry UCLA School of Dentistry
 Hassablla: principles of complete denture prosthodontics, by , 2nd edition p.233-235
 Chandrasekharan.NK et al, A Technique for Impressing the Severely Resorbed Mandibular Edentulous Ridge, Journal of
Prosthodontics, 2012; 21: 215–218
 Dwivedi A, Vyas R, Theories of impression making and their rationale in complete denture prosthodontics. J Orafac Res
2013;3(1):34-37
 Goodacre et al, CAD/CAM fabricated complete dentures: concepts and clinical methods of obtaining required morphological
data, J Prosthet Dent 2012;107:34-46
 Infante et al, Fabricating complete dentures with CAD/CAM technology,J Prosthet Dent 2014
 Komiyama O et al, Effects of relief space and escape holes on pressure characteristics of maxillary edentulous impressions,
J Prosthet Dent 2004;91:570-6
 McCord.JF ,Grant.AA ,Impression making, BDJ, 2000 ;188: 9, pp 484 – 92
 Nair KC, A primer on complete denture fabrication, 1st edition, 2013, Ahuja publication, India Pp 67-77
 Rao.S etal, A Systematic Review of Impression Technique for Conventional Complete Denture, J Indian Prosthodont Soc
(Apr-June 2010) 10(2):105–111
 Rudd and Morrow, Dental lab procedures, Complete dentures, 2nd edition, 1986, Mosby Publications, USA, Pp 9 - 89
 Sharry .J.J, Complete denture Prosthodontics, 3rd edition, Mc Graw Hill company, pp 191-210.
 Sheldon Winkler, Essentials of complete Denture prosthodontics, 2nd edition,2012, AITBS Publishers, India, pp 88-105
 Zarb G, Hobkirk JA, Eckert SE, Jacob RF, editors. Prosthodontic treatment for edentulous patients. 13th ed. St. Louis:
Elsevier Mosby; 2013 pp 161-179
 Zimmer I.D. and Sherman, H. An analysis of the development of complete denture impression techniques. J Prosthet dent
46: 242-249, 1981.
References

Questions:
I. Discuss the Prosthodontic importance of:
1. Buccal shelf area
2. Fovea palatinae
3. Incisive papilla
4. Palatine vault .
II. Discuss border structures that limits the periphery of the
maxillary denture. • Discuss border structures that limits the
periphery of the mandibular denture.

‫الصخر‬ ‫في‬ ‫تحفر‬ ‫المطر‬ ‫قطرة‬
‫بالتكرار‬ ‫ولكن‬ ‫بالعنف‬ ‫ليس‬
A rain drop digs in the rock
Not by violence but by repetition

Impression philosophies for completely edentulous patients

Impression philosophies for completely edentulous patients

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