278

Volume 101 Issue 4

25.Rosentritt M, Behr M, Gebhard R, Handel
G. Influence of stress simulation parameters on the fracture strength of all-ceramic fixed-partial dentures. Dent Mater
2006;22:176-82.
26.Heintze SD, Cavalleri A, Forjanic M, Zellweger G, Rousson V. A comparison of three
different methods for the quantification of
the in vitro wear of dental materials. Dent
Mater 2006;22:1051-62.

Corresponding author:
Dr Sebastian Hahnel
Department of Prosthetic Dentistry
Regensburg University Medical Center
93042 Regensburg
GERMANY
Fax: +49-941-944-6171
E-mail: Sebastian.Hahnel@klinik.uni-regensburg.de

Acknowledgements
The authors thank Ivoclar Vivadent, Schaan,
Liechtenstein, for supplying products for this
investigation.

Modified fluid wax impression for a

severely resorbed edentulous
mandibular ridge

Copyright 2009 by the Editorial Council for

The Journal of Prosthetic Dentistry.

Kian M. Tan, BDS,a Michael T. Singer, DDS, MS,b Radi Masri,

BDS, MS, PhD,c and Carl F. Driscoll, DMDd
Baltimore College of Dental Surgery, University of Maryland,
Baltimore, Md

Noteworthy Abstracts of the Current Literature

Fractographic analyses of zirconia-based fixed partial dentures
Taskonak B, Yan J, Mecholsky JJ Jr, Sertgz A, Koak A.
Dent Mater 2008;24:1077-82.
Objectives: Advances in ceramic processing techniques enable clinicians and ceramists to fabricate all-ceramic fixed
partial dentures (FPDs) for posterior regions using high-strength yttria-stabilized tetragonal zirconia polycrystals (YTZP). However, failures occur in ceramic FPDs due to their design. The objectives of this study were to determine the
site of crack initiation and the causes of fracture in clinically failed zirconia-based ceramic FPDs.
Methods: Five clinically failed four-unit Y-TZP-based FPDs (Cercon ceramics, DeguDent GmbH, Hanau, Germany)
were retrieved and analyzed. The fragments containing the fracture origins in the veneers (Cercon Ceram S Veneering Ceramic, DeguDent GmbH, Hanau, Germany) of two samples were missing but the rest of veneer structures
were present. The other three samples had their veneers intact. Fracture surfaces were examined using fractographic
techniques, utilizing both optical and scanning electron microscopes (SEM). Quantitative fractography and fracture
mechanics principles were used to estimate the stresses at failure.
Results: Primary fractures initiated from the gingival surfaces of connectors at veneer surfaces in four out of the five
samples. However, critical flaw sizes could be measured in three of the five cases since fracture origins were lost in the
remaining two due to local fragmentation at the crack initiation site. Delaminations between glass veneer and zirconia
core were observed in Y-TZP-based FPDs and a secondary fracture initiated from the zirconia core. Secondary fracture
controlled the ultimate failure. Failure stresses of the fixed partial dentures that failed due to zirconia fracture ranged
from 379 to 501 MPa. Fractures that had origins on the glass veneer surface had failure stresses between 31 and 38
MPa.
Significance: Primary fractures in clinically failed Y-TZP-based FPDs initiated from the veneer surfaces. Interfacial delamination in glass veneer/zirconia core bilayer dental ceramic structures controlled the secondary fracture initiation
sites and failure stresses in Y-TZP-based fixed partial dentures.
Reprinted with permission from the Academy of Dental Materials.

This article describes a technique for making a definitive impression for highly displaceable residual ridges. The technique is especially applicable for mandibular edentulous ridges. The choice of the impression materials, as well as the
design of the impression tray, focuses on preventing distortion of the displaceable residual ridges during impression
making. Using an impression tray with an opening, modeling plastic impression compound and impression wax are
used to accurately capture the shape of the residual ridge and place pressure onto denture load-bearing areas. Lowviscosity vinyl polysiloxane impression material is then used over the window opening to capture the surface details of
the residual ridge without distorting the displaceable tissues. The use of this technique helps in maintaining the contour and capturing the detail of the tissues, as well as in accurately determining the extent of the muccobuccal denture
extensions. ( J Prosthet Dent 2009;101:279-282)
Making a definitive impression of
an edentulous arch can be challenging when the residual ridges present
with less-than-ideal conditions, especially when there is minimal bone
height, unfavorable residual ridge
morphology, and/or unfavorable
muscle attachments.1 Impressions
are also challenging when the mucosa
overlying the residual alveolar ridges is
highly displaceable. Displaceable, hyperplastic, or flabby tissues are commonly seen in the anterior region of
the maxilla in combination syndrome2
or in the mandibular alveolar ridge
when extensive bone resorption has
occurred.3 Displacing such residual
ridge tissues during impression making is always a concern. Soft tissues
that are displaced during impression
making tend to return to their original
form, and complete dentures fabricated from the impression will not fit
accurately on the recovered tissues. As
a result, loss of retention and stability
of the dentures, discomfort, and gross
occlusal disharmony may occur.4

Most impression techniques for

the management of displaceable tissues have been described for the anterior maxilla,5,6 and techniques to
manage displaceable tissues in the
mandible during impression making
are rarely reported. Due to the anatomical differences between the maxilla and the mandible, as well as the
differences in primary and secondary
load-bearing areas, impressions of
mandibular ridges with displaceable
tissues require special considerations.
A classic impression technique
commonly used for the fabrication
of immediate complete dentures7 or
the treatment of patients with combination syndrome5 uses a custom
impression tray with a window opening in the anterior region. When the
maxillary edentulous ridge presents
with anterior hyperplastic tissues,
a zinc oxide eugenol impression is
first made, and a creamy mix of impression plaster is then painted onto
the displaceable tissues.5 Impression
plaster produces little pressure, but

Postgraduate Prosthodontics Resident.

Clinical Assistant Professor; private practice, Bethesda, Md.
c
Assistant Professor.
d
Professor, Program Director.
a

The Journal of Prosthetic Dentistry

Hahnel et al

Tan et al

it is difficult to handle and difficult

to pour8 and offers little advantage
over contemporary low-viscosity vinyl
polysiloxane materials.
Mandibular residual ridges with
adequate bone support can usually
be precisely recorded with elastomeric impression materials because of
the inherent accuracy of these materials and their propensity to distribute
pressure equally. As the residual ridges resorb, the tissues become unsupported and displaceable; the use of an
elastomeric impression material in a
confined tray will result in a distorted
impression. Therefore, the impression
technique should be modified to prevent distortion of unsupported and
displaceable tissues. A functional impression technique, such as fluid wax,
captures the primary and secondary
load-bearing areas without distortion
of the residual ridge. In the mandible,
the alveolar residual ridge serves as a
secondary load-bearing area, with the
buccal shelves serving as the primary
load-bearing area.9,10

280

Volume 101 Issue 4

According to Applegate,11 the use

of fluid wax in impression making was
described previously by Everett. It has
the following advantages: (1) it can
be easily controlled to gain maximum
coverage; (2) it can be corrected readily; (3) it can be used to accurately determine the extent of the muccobuccal reflections; and (4) it can be used
to direct pressure to the load-bearing
areas, specifically, the buccal shelves
and the slopes of residual ridges in the
mandible.10,11 The low-viscosity elastomeric impression material is advantageous because it creates minimal
pressure, produces accurate details,
does not distort easily, and is easy to
handle.12,13
An alternative method of making
a definitive impression for mandibular
edentulous arches with displaceable
tissues, using impression wax and vinyl polysiloxane impression material,
is described.

1 Mandibular edentulous ridge with severe bone resorption.

281

April 2009

4 Fluid wax impression.

5 Application of vinyl polysiloxane impression material

over window opening.

6 Completed modified fluid wax impression.

7 Boxing of impression.

TECHNIQUE
1. Make a preliminary impression
of the edentulous arch (Fig. 1) using
irreversible hydrocolloid impression
material (Jeltrate Alginate; Dentsply
Caulk, Milford, Del) in a metal stock
tray (Rim-Lock Impression Tray;
Dentsply Caulk).
2. Pour the impression in type III
dental stone (Modern Materials Denstone; Heraeus Kulzer, Armonk, NY)
(Fig. 2).
3. Fabricate a custom impression
tray on the preliminary cast using
light-polymerized acrylic resin tray
material (Triad TruTray; Dentsply Trubyte, York, Pa). Adjust the border extension of the tray to be at least 2 mm
short of the vestibules on the preliminary cast.9
4. Evaluate and adjust the extension of the tray in the mouth, if necessary. Soften modeling plastic impression compound (Gray Stick; Kerr
Corp, Orange, Calif ) in a water bath
at 53C, and place it on the intaglio
surface of the tray, corresponding to
the region of the mandibular central
incisors and both the mandibular first

2 Preliminary cast. Note distortion of left alveolar ridge lingually due

to pressure exerted by irreversible hydrocolloid impression material.

3 Window opening of impression tray.

molars, to serve as spacers for impression wax.
5. Border mold the tray with modeling plastic impression compound in
segments.
6. Remove the spacers with a scalpel blade (Becton, Dickinson and Co,
Franklin Lakes, NJ) once the border
molding is completed.
7. Trim the tray over the crest of

The Journal of Prosthetic Dentistry

the residual ridge, and create a window opening above the displaceable
alveolar ridge using a No. 8 round
bur (Brasseler USA, Savannah, Ga),
similar to the tray design described
by Watson.5 Determine the size of the
window opening according to the extent of the displaceable tissues (Fig.
3).
8. Melt the mouth temperature im-

Tan et al

pression wax (D-R Miner Dental Waxes, Medford, Ore) in a container held
in a water bath at 42C, and apply
the impression wax onto the borders
of the tray with a wax spatula while it
is still fluid. Ensure that the temperature used to melt the impression wax
is less than the working temperature
of the modeling plastic impression
compound used in the border molding procedure, to prevent distortion.
9. Place the impression tray immediately over the edentulous ridge, and
leave it in the mouth for approximately 5 minutes. Allow adequate time for
the mouth temperature impression
wax to flow and escape to the periphery of the impression, as well as to
solidify.
10. Remove the impression tray
from the mouth and cool it immediately in water at room temperature.
11. Add impression wax in increments on the periphery until a defi-

Tan et al

nite reproduction of the muccobuccal

fold is obtained.
12. Apply impression wax onto the
intaglio surface of the tray to capture
the remaining surfaces of the residual
ridge. Add impression wax onto the
slopes of the ridge, rather than the
crest, in increments,10 until a glossy
surface is visible.11 Maintain the integrity of the residual ridge by exerting
pressure onto the slopes (Fig. 4).
13. Trim away any excess impression wax on the periphery or over
the window opening with a scalpel
blade.
14. Apply adhesive (Caulk Tray
Adhesive; Dentsply Caulk) on the tray
in the area surrounding the window
opening, and allow it to dry.
15. Place the impression tray
onto the residual ridge and inject vinyl polysiloxane impression material
(Aquasil Ultra Monophase Regular
Set Smart Wetting Impression Mate-

rial; Dentsply Caulk) over the window

opening. Prevent distortion of the
soft tissues by placing the impression
material in the most passive manner
possible.
16. Gently blow air onto the impression material to allow the spread
of the impression material over the
mucosal surfaces.
17. Allow the impression material
to polymerize according to the manufacturers recommendation (Figs. 5
and 6).
18. Remove, disinfect, and box the
impression using a mix of plaster and
pumice as described by Martin et al
(Fig. 7).14 Avoid using a conventional
boxing procedure that requires boxing wax, as it may distort the impression wax.
19. Pour the impression in type
III dental stone (Modern Materials
Denstone; Heraeus Kulzer) as soon as
possible (Fig. 8).

280

Volume 101 Issue 4

According to Applegate,11 the use

of fluid wax in impression making was
described previously by Everett. It has
the following advantages: (1) it can
be easily controlled to gain maximum
coverage; (2) it can be corrected readily; (3) it can be used to accurately determine the extent of the muccobuccal reflections; and (4) it can be used
to direct pressure to the load-bearing
areas, specifically, the buccal shelves
and the slopes of residual ridges in the
mandible.10,11 The low-viscosity elastomeric impression material is advantageous because it creates minimal
pressure, produces accurate details,
does not distort easily, and is easy to
handle.12,13
An alternative method of making
a definitive impression for mandibular
edentulous arches with displaceable
tissues, using impression wax and vinyl polysiloxane impression material,
is described.

1 Mandibular edentulous ridge with severe bone resorption.

281

April 2009

4 Fluid wax impression.

5 Application of vinyl polysiloxane impression material

over window opening.

6 Completed modified fluid wax impression.

7 Boxing of impression.

TECHNIQUE
1. Make a preliminary impression
of the edentulous arch (Fig. 1) using
irreversible hydrocolloid impression
material (Jeltrate Alginate; Dentsply
Caulk, Milford, Del) in a metal stock
tray (Rim-Lock Impression Tray;
Dentsply Caulk).
2. Pour the impression in type III
dental stone (Modern Materials Denstone; Heraeus Kulzer, Armonk, NY)
(Fig. 2).
3. Fabricate a custom impression
tray on the preliminary cast using
light-polymerized acrylic resin tray
material (Triad TruTray; Dentsply Trubyte, York, Pa). Adjust the border extension of the tray to be at least 2 mm
short of the vestibules on the preliminary cast.9
4. Evaluate and adjust the extension of the tray in the mouth, if necessary. Soften modeling plastic impression compound (Gray Stick; Kerr
Corp, Orange, Calif ) in a water bath
at 53C, and place it on the intaglio
surface of the tray, corresponding to
the region of the mandibular central
incisors and both the mandibular first

2 Preliminary cast. Note distortion of left alveolar ridge lingually due

to pressure exerted by irreversible hydrocolloid impression material.

3 Window opening of impression tray.

molars, to serve as spacers for impression wax.
5. Border mold the tray with modeling plastic impression compound in
segments.
6. Remove the spacers with a scalpel blade (Becton, Dickinson and Co,
Franklin Lakes, NJ) once the border
molding is completed.
7. Trim the tray over the crest of

The Journal of Prosthetic Dentistry

the residual ridge, and create a window opening above the displaceable
alveolar ridge using a No. 8 round
bur (Brasseler USA, Savannah, Ga),
similar to the tray design described
by Watson.5 Determine the size of the
window opening according to the extent of the displaceable tissues (Fig.
3).
8. Melt the mouth temperature im-

Tan et al

pression wax (D-R Miner Dental Waxes, Medford, Ore) in a container held
in a water bath at 42C, and apply
the impression wax onto the borders
of the tray with a wax spatula while it
is still fluid. Ensure that the temperature used to melt the impression wax
is less than the working temperature
of the modeling plastic impression
compound used in the border molding procedure, to prevent distortion.
9. Place the impression tray immediately over the edentulous ridge, and
leave it in the mouth for approximately 5 minutes. Allow adequate time for
the mouth temperature impression
wax to flow and escape to the periphery of the impression, as well as to
solidify.
10. Remove the impression tray
from the mouth and cool it immediately in water at room temperature.
11. Add impression wax in increments on the periphery until a defi-

Tan et al

nite reproduction of the muccobuccal

fold is obtained.
12. Apply impression wax onto the
intaglio surface of the tray to capture
the remaining surfaces of the residual
ridge. Add impression wax onto the
slopes of the ridge, rather than the
crest, in increments,10 until a glossy
surface is visible.11 Maintain the integrity of the residual ridge by exerting
pressure onto the slopes (Fig. 4).
13. Trim away any excess impression wax on the periphery or over
the window opening with a scalpel
blade.
14. Apply adhesive (Caulk Tray
Adhesive; Dentsply Caulk) on the tray
in the area surrounding the window
opening, and allow it to dry.
15. Place the impression tray
onto the residual ridge and inject vinyl polysiloxane impression material
(Aquasil Ultra Monophase Regular
Set Smart Wetting Impression Mate-

rial; Dentsply Caulk) over the window

opening. Prevent distortion of the
soft tissues by placing the impression
material in the most passive manner
possible.
16. Gently blow air onto the impression material to allow the spread
of the impression material over the
mucosal surfaces.
17. Allow the impression material
to polymerize according to the manufacturers recommendation (Figs. 5
and 6).
18. Remove, disinfect, and box the
impression using a mix of plaster and
pumice as described by Martin et al
(Fig. 7).14 Avoid using a conventional
boxing procedure that requires boxing wax, as it may distort the impression wax.
19. Pour the impression in type
III dental stone (Modern Materials
Denstone; Heraeus Kulzer) as soon as
possible (Fig. 8).

282

Volume 101 Issue 4

8 Resultant definitive cast.

SUMMARY
A definitive impression technique
using both impression wax and vinyl polysiloxane impression material
for displaceable mandibular residual
ridges is described. Consideration has
been given to the choice of impression materials as well as to the design
of the impression tray to minimize the
amount of pressure exerted onto the
displaceable regions of the residual
ridges during the impression-making
procedure.

REFERENCES
1. McGarry TJ, Nimmo A, Skiba JF, Ahlstrom
RH, Smith CR, Koumjian JH. Classification system for complete edentulism. The
American College of Prosthodontics. J
Prosthodont 1999;8:27-39.
2. Kelly E. Changes caused by a mandibular
removable partial denture opposing a
maxillary complete denture. J Prosthet Dent
1972;27:140-50.
3. Xie Q, Nrhi TO, Nevalainen JM, Wolf
J, Ainamo A. Oral status and prosthetic
factors related to residual ridge resorption
in elderly subjects. Acta Odontol Scand
1997;55:306-13.
4. Lytle RB. The management of abused oral
tissues in complete denture construction. J
Prosthet Dent 1957;7:27-42.

5. Watson RM. Impression technique

for maxillary fibrous ridge. Br Dent J
1970;128:552.
6. Lynch CD, Allen PF. Management of the
flabby ridge: using contemporary materials to solve an old problem. Br Dent J
2006;200:258-61.
7. Campagna SJ. An impression technique
for immediate dentures. J Prosthet Dent
1968;20:196-203.
8. Freeman SP. Impressions for complete dentures. J Am Dent Assoc 1969;79:1173-8.
9. Zarb GA, Bolender CL, Eckert SE, Fenton
AH, Jacob RF, Mericske-Stein R. Prosthodontic treatment for edentulous
patients: complete dentures and implantsupported prostheses. 12 ed. St. Louis:
Mosby; 2003. p. 232-33, 246.
10.Boucher CO. A critical analysis of midcentury impression techniques for full
dentures. J Prosthet Dent 1951;1:472-91.
11.Applegate OC. Essentials of removable partial denture prosthesis. 3rd ed. Philadephia:
WB Saunders; 1965. p. 254-5.
12.Al-Ahmad A, Masri R, Driscoll CF, von
Fraunhofer J, Romberg E. Pressure generated on a simulated mandibular oral
analog by impression materials in custom
trays of different design. J Prosthodont
2006;15:95-101.
13.Masri R, Driscoll CF, Burkhardt J, Von
Fraunhofer A, Romberg E. Pressure generated on a simulated oral analog by impression materials in custom trays of different
designs. J Prosthodont 2002;11:155-60.
14.Martin JW, Jacob RF, King GE. Boxing the
altered cast impression for the dentate
obturator by using plaster and pumice. J
Prosthet Dent 1988;59:382-4.
Corresponding author:
Dr Radi Masri
650 West Baltimore St, Room 4228
Baltimore, MD 21201
Fax: 410-706-1565
E-mail: rmasri@umaryland.edu
Copyright 2009 by the Editorial Council for
The Journal of Prosthetic Dentistry.

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Method for fabrication of a cast

mounting device with interchangeable
occlusal templates
Jimmy Londono, DDS,a and Philip S. Baker, DDSb
School of Dentistry, Medical College of Georgia, Augusta, Ga
The cast mounting device is an index for positioning a patients maxillary cast within the dental articulator.
This technique is commonly based
upon average measurements made
from anatomic landmarks. Although
many studies1-23 have investigated
arbitrary or kinematic facebows to
determine whether they are more accurate methods for cast orientation,
controversy over their use continues.24
Some commercial mounting devices currently available are the Artex
Set Up Templates for Complete Dentures (Amann Girrbach AG, Koblach,
Austria), the Denar HIP Mounting
Platform (Whip Mix Corp, Louisville,
Ky), and the Quick Master Articulator System Mounting Table (FAG
Dentaire, Cluses, France). The Artex
index is designed for use only in complete denture treatment, while the
Denar Platform and the Quick Master Mounting Tables are intended for
dentulous as well as edentulous patient applications.
The primary limitation of these
commercial devices is their lack of
interchangeability with other manufacturers articulator systems. Unless
the dentist uses the appropriate articulator with a specific cast mounting device, it cannot be ensured that
the components will be compatible in
either fit or orientation.
The purpose of this article is to
describe a simple, quick, and inexpensive method for fabricating a
mounting device with interchange-

able occlusal templates for orienting

the maxillary cast in articulators using
mounting plates. It may permit use of
a single duplicate template on multiple brands and models of articulators, when appropriate template bases have been made using the outlined
technique. Alternatively, multiple occlusal templates could be fabricated
to fit a single base made for a specific
model, system, or brand of articulator, depending on the manufacturers
design.

PROCEDURE
1. Using a vacuum forming device
(UltraVac Vacuum Former; Ultradent
Products, Inc, South Jordan, Utah),
duplicate the metal occlusal template
(Trubyte 20 Degree Posterior Template; Dentsply Intl, York, Pa) with
0.080-inch hard, clear splint material
(Henry Schein, Inc, Melville, NY).
2. Trim the thermoplastic sheet to
the original external template outline
with a vacuum form trimming bur
(Brasseler H219S.11.023; Brasseler
USA, Savannah, Ga). Do not remove
material from the lingual area.
3. Secure a mounting plate to
the lower member of the articulator
of choice. Center an inverted 6-oz
waxed paper cup (Solo Cup Co, Highland Park, Ill) on top of the mounting plate. Position the duplicated,
trimmed template on the cup and
determine the appropriate cup height
to establish the desired occlusal plane
level within the articulator. Trimming

Clinical Instructor, Department of Oral Rehabilitation.

Associate Professor, Department of Oral Rehabilitation.

(J Prosthet Dent 2009;101:283-284)

The Journal of Prosthetic Dentistry

Tan et al

Londono and Baker

from the open end of the cup, reduce

it approximately 10 mm more than
the required final plane height.
4. Obtain an indexed dowel pin
and matching sleeve (MR PIN - Dual
Pin and Sleeve; Select Dental Mfg
Co, Farmingdale, NY). Using a pencil
point, place a hole in the center of the
cup bottom with a diameter slightly
greater than the widest diameter of
the dowel sleeve. Mix mounting stone
(Mounting Stone; Whip Mix Corp)
and fill the modified cup. Place some
of the remaining mounting stone into
the retentive features of the mounting plate on the articulator. Invert the
stone-filled cup and place it on top of
the loaded mounting plate, adjusting
for correct alignment as needed. Remove any excess stone expressed from
the opening in the bottom of the cup,
so that it is approximately at the height
of the original paper bottom. Prior to
initial stone set, embed the single pin
end of the dowel pin patrix in the centered cup hole, with the pin oriented
perpendicular to the table top and
pin shoulder at the level of the stone
surface. Note that the template base
is now completed (Fig. 1, A).
5. Place a hole in the center of the
duplicate 20-degree template using
a medium acrylic resin trimming bur
(Brasseler E-Cutter H79E-050; Brasseler USA); the hole should allow passage of the matrix sleeve of the dowel
pin. Seat the matrix fully on the patrix. Place the template on the seated
sleeve, avoiding dislodgement of the
sleeve from the patrix. Position the