CLI NI CAL REPORT

Management of Compromised Ridges: A Case Report

Smita Sara Manoj

Vidya Chitre

Meena Aras
Received: 1 November 2010 / Accepted: 7 May 2011 / Published online: 27 May 2011
Indian Prosthodontic Society 2011
Abstract Complete denture therapy is an age old form of
dental treatment. Ridge atrophy poses a clinical challenge
towards the fabrication of a successful prosthesis. Extreme
resorption of the maxillary and mandibular denture bearing
areas results in sunken appearance of cheeks, unstable and
non retentive dentures with associated pain and discomfort.
This article describes the step by step rehabilitation pro-
cedure of a patient with atrophic ridges using a hollow
maxillary complete denture with cheek plumpers attached
to it and the recording of neutral zone to ensure a stable
mandibular denture.
Keywords Ridge atrophy Residual ridge resorption
Admix impression Neutral zone Hollow maxillary
complete denture
Residual ridge resorption is a complex biophysical process
and a common occurrence following extraction of teeth.
Ridge atrophy is most dramatic during the rst year after
tooth loss followed by a slower but more progressive rate
of resorption thereafter [1, 2]. The various factors [1, 38]
inuencing ridge resorption are
1) Anatomic factors
Rate of vertical bone loss in a broad high ridge is
slower than that of a small ridge
Denser the bone, slower will be the rate of
resorption
2) Metabolic factors bone metabolism is dependent on
cell metabolism (especially osteoblasts and
osteoclasts)
PTH imbalance
Post menopausal osteoporosis
Continuous synthesis of local prostaglandins
Hypervitaminosis A and D
Hypovitaminosis C
3) Mechanical factors
a) Functional factors
Frequency, direction and strength of forces
acting on bone
Bruxism
b) Prosthetic factors
Type and t of prosthesis
Duration of prosthodontic treatment
Hours of prosthesis wearing per day
Occlusal disharmony
Lack of prosthodontic treatment (disuse
atrophy)
Treatment of atrophied ridges is a clinical challenge faced
by dentists world wide. Severely resorbed ridges present
difculty in fabrication of an adequate prosthesis. This article
presents a step by step method of rehabilitating a patient with
severely resorbed maxillary and mandibular alveolar ridges.
S. S. Manoj (&)
Department of Prosthodontics, Azeezia College of Dental
Science and Research Center, Diamond Hillsm, Meeyyanoor,
Kollam, Kerala, India
e-mail: [email protected]
V. Chitre M. Aras
Department of Prosthodontics, Goa Dental College and Hospital,
Bambolim, Goa
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J Indian Prosthodont Soc (Apr-June 2011) 11(2):125129
DOI 10.1007/s13191-011-0068-7
Case Report
A sixty ve year old male patient reported to the Depart-
ment Of Prosthodontics, Government Dental College, Goa
with the chief complaint of replacement of existing den-
tures. The patient gave a history of loss of teeth over a
period of three to ve years. The patient was edentulous for
the past fteen years and was wearing complete denture
prosthesis since then. The existing dentures were loose and
ill-tting causing discomfort. He was also not happy with
the sunken appearance of his cheeks.
Treatment Plan
Clinical evaluation revealed resorbed maxillary ridge with
sunken cheeks, at (atrophic) mandibular ridge [Figures 1,
2 & 3] and increased interarch space. The existing dentures
were unstable and non retentive.
After a thorough evaluation of the patients history,
radiographs and existing clinical conditions, the various
treatment options were discussed. The patient did not give
any relevant medical history that could have possibly
contributed to ridge resorption. Treatment options included
pre-prosthetic surgeries followed by conventional complete
denture prosthesis, implant supported prosthesis, conven-
tional complete denture prosthesis [1, 6]. However, the
patient was not interested in any surgical intervention and
opted for a conventional complete denture. Finally, it was
decided to rehabilitate the patient with a hollow maxillary
complete denture with attached cheek plumpers and a
conventional mandibular denture.
Clinical Procedure
The primary impressions were made using impression
compound. Maxillary custom tray was fabricated using a
full spacer design with additional wax relief over the
anterior ridge, incisive papilla, mid-palatine raphe and
tuberosity areas. Mandibular custom tray was fabricated to
provide a space of 4 mm using two wax spacers for the
admix impression material.
Maxillary secondary impression was made using zinc
oxide eugenol impression paste. The mandibular secondary
impression was made using an admix of three parts by
weight of impression compound and seven parts by weight
of tracing compound [Figure 4].
After the registration of maxillo-mandibular relations,
the casts were mounted on an articulator. Zero degree
maxillary teeth were arranged to monoplane articulation
and a wax try-in was done. The sunken cheeks were Fig. 1 Patient without the prosthesis
Fig. 2 Atrophic maxillary ridge
Fig. 3 Atrophic mandibular ridge
126 J Indian Prosthodont Soc (Apr-June 2011) 11(2):125129
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plumped by adding and contouring excess wax on the
buccal surface of the maxillary record base.
Mandibular neutral zone impression was recorded
using the anthropoidal pouch [9] technique (neutral zone
technique) [Figure 5]. In this technique, the mandibular
wax occlusal rim was removed and retentive wire loops
were attached to the acrylic resin record base. Compound
was kneaded and adapted to the mandibular denture base.
Maxillary record base was placed in the patients mouth
followed by placement of the mandibular record base with
softened compound. The patient was asked to carry out
different functional movements like sucking, swallowing,
smiling, licking the lips, whistling, pronouncing vowels
and counting. Excess compound was trimmed away and
the material was resoftened and placed back into the
mouth asking the patient to repeat the functional move-
ments. Plaster index of the impression was made and the
mandibular teeth were arranged in the neutral zone fol-
lowing the index [Figure 6 & 7]. Final try-in procedures
were completed and the dentures were processed and
nished.
Laboratory Procedure
The hollow maxillary complete denture was fabricated
using the two ask technique described by Fattore et al [10]
which was a variation of the technique originally described
by Chalian and Barnett [11] for fabrication of hollow bulb
portion of obturator prosthesis using autopolymerized
acrylic resin shims. The try-in maxillary denture was
invested and dewaxed. Baseplate wax was then adapted to
the tooth side and cast side of the dental ask [Figure 8].
New asks whose halves would t the original ask were
selected and placed over the original ask containing teeth
Fig. 4 Maxillary (zinc oxide eugenol) and mandibular (admix)
secondary impressions
Fig. 5 Mandibular neutral zone impression
Fig. 6 Plaster index for the neutral zone impression
Fig. 7 Mandibular teeth arranged in the neutral zone
J Indian Prosthodont Soc (Apr-June 2011) 11(2):125129 127
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and cast with wax adapted over them. Dental stone was
poured into the alternate halves of the ask and invested.
Following dewaxing, pigmentation was done on the
teeth side of the mould cavity so that it could be transferred
on to the labial surface of the nal denture. The asks were
then packed with high impact heat cure acrylic resin and
cured. Both halves of the original ask now contained a
processed acrylic resin shell [Figure 9]. The two halves
were tted together to remove any acrylic resin that would
interfere with complete ask closure. A rope of heat cure
acrylic resin was then adapted around the borders of cured
acrylic resin shell on the tooth side of the ask. Following
trial closure, the two halves of ask were closed and cured
using a long curing cycle. Once processed, the denture base
was nished and polished [Figure 10].
The denture borders were evaluated for any uid seepage
into the denture cavity by weighing it before and after
placement in water for a day. Once the seal was evaluated, the
dentures were inserted in the patients mouth [Figure 11].
The patient was reviewed after a week and minor den-
ture related complaints were corrected. After that the
patient never reported back to the department.
Discussion
Severe ridge atrophy results in increased inter-arch space,
unstable and non retentive mandibular dentures with
inability to withstand the masticatory forces. The negative
Fig. 8 Baseplate wax adapted to the tooth and cast side of the ask
after investing and dewaxing of the maxillary record base
Fig. 9 Processed acrylic resin shells that will be fused together later
by adapting a rope of heat cured acrylic resin around the borders
Fig. 10 Hollow maxillary complete denture with attached cheek
plumpers and conventional mandibular denture
Fig. 11 Patients restored smile
128 J Indian Prosthodont Soc (Apr-June 2011) 11(2):125129
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effects of ridge atrophy were managed by modifying the
conventional procedures of fabricating a complete denture.
In this case a hollowmaxillary complete denture was given
in order to decrease the weight of prosthesis. However, a
conventional mandibular denture was given as it has been
suggested though universally not accepted that gravity and
addition of weight to the mandibular complete denture may
aid in retention of the prosthesis [12]. Admix impression
technique described by McCord and Tyson was used to record
the mandibular secondary impression [9, 13]. The philosophy
was that 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 dis-
comfort arising from the atrophic sandwich i.e. the creased
mucosa lying between the denture base and mandibular bone.
Neutral zone mandibular impression was recorded in order
to determine the space within which the denture could be
seated without being subjected to excessive displacing forces
from the surrounding musculature and thus aid in denture
base stability. Neutral zone is dened as the potential space
between the lips and cheeks on one side and the tongue on the
other; that area or position where the forces between the
tongue and cheeks or lips are equal [1416].
Maxillary neutral zone impression was not recorded as the
effect of tongue size and position do not appear to have as
profound an impact on the stability of a maxillary denture as
compared to the mandibular denture. Besides, the position of
the mandibular teeth arranged in the neutral zone was used as
a guide to position the maxillary teeth in the neutral zone [17].
Zero-degree teethwere arrangedtoa monoplane articulation
toallowthe patient toclenchandgrindinandaroundmaximum
intercuspation during both functional and non-functional
activities and also to aid in denture stability as large cuspal
forms tend to induce instability via a tripping effect [18, 19].
Conclusion
Prosthodontic rehabilitation of a patient with compromised
edentulous ridges in a conventional manner is a difcult
task. Modications in the treatment procedures should be
considered to full the patients functional and esthetic
desires. Though unconventional, a hollow maxillary com-
plete denture can be given to a patient with severe ridge
atrophy and increased inter-arch space.
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