|Year : 2022 | Volume
| Issue : 2 | Page : 165-171
Fabrication of hollow denture technique for highly resorbed ridges for geriatric cases-A literature review
Deepa Balu, Ahila Singaravel Chidembaranathan, Muthukumar Balasubramaniam
Department of Prosthodontics, SRM Dental College, SRM University, Chennai, Tamil Nadu, India
|Date of Submission||20-Jan-2022|
|Date of Decision||29-Jan-2022|
|Date of Acceptance||12-Feb-2022|
|Date of Web Publication||01-Jul-2022|
Ahila Singaravel Chidembaranathan
Department of Prosthodontics, SRM Dental College, SRM University, Ramapuram, Chennai - 600 089, Tamil Nadu
Source of Support: None, Conflict of Interest: None
The purpose of the review was to validate the different methods used for the fabrication of hollow denture that gives the better retention and stability in highly resorbed conditions. This study includes various literatures that provide different techniques involved during for fabrication process of hollow denture and also incorporation of the various different materials such as salt, sugar crystals, chocolate syrup, soap, and latest advances including the three-dimensional (3D) resins that are used as the spacer material in the fabrication of these dentures. The results show that all these different techniques using the different spacer material possess the similar results of 25% reduction in weight of the dental prosthesis. There are increased retention, stability, and comfort in condition of highly resorbed conditions with increased interocclusal distance that also prevents the muscle atrophy and fatigue in elderly individuals.
Keywords: Hollow denture, resorbed ridge, retention, wax spacer
|How to cite this article:|
Balu D, Chidembaranathan AS, Balasubramaniam M. Fabrication of hollow denture technique for highly resorbed ridges for geriatric cases-A literature review. J Oral Res Rev 2022;14:165-71
|How to cite this URL:|
Balu D, Chidembaranathan AS, Balasubramaniam M. Fabrication of hollow denture technique for highly resorbed ridges for geriatric cases-A literature review. J Oral Res Rev [serial online] 2022 [cited 2022 Aug 16];14:165-71. Available from: https://www.jorr.org/text.asp?2022/14/2/165/349707
| Introduction|| |
Extreme resorption of the maxillary denture-bearing area may lead to problems with prosthetic rehabilitation. These may be due to a narrower, more constricted residual ridge as resorption progresses, decreased supporting tissues, and a resultant large restorative space between the maxillary residual ridge and opposing mandibular teeth. The latter may result in a heavy maxillary complete denture that may compound the poor denture-bearing ability of the tissues and lead to decreased retention and resistance. Although not universally accepted, it has been suggested that gravity and the addition of weight to the mandibular complete denture may aid in prosthesis retention. Residual ridge resorption is a complex biophysical process and a common occurrence following extraction of teeth. Ridge atrophy is most dramatic during the 1st year after tooth loss followed by a slower but more progressive rate of resorption thereafter., The various factors influencing ridge resorption, are as follows:
- 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
Metabolic factors – bone metabolism is dependent on cell metabolism (especially osteoblasts and osteoclasts)
- PTH imbalance
- Postmenopausal osteoporosis
- Continuous synthesis of local prostaglandins
- Hypervitaminosis A and D
- Hypovitaminosis C
- Functional factors
- Frequency, direction, and strength of forces acting on bone
- Type and fit 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 worldwide. The clinical condition of resorbed maxillary ridge showed sunken cheeks, flat (atrophic) mandibular ridge and increased interarch space. The treatment options include for such conditions begins with preprosthetic surgeries followed by conventional complete denture prosthesis, implant-supported prosthesis, complete denture prosthesis and also the hollow maxillary complete denture which would be more lightweight and more comfort when compared to the conventional complete denture due to the reduction in amount of acrylic during the denture fabrication.
| Different Techniques for Fabrication of Hollow Denture|| |
Hollow denture using the two-flask technique
The hollow maxillary complete denture was fabricated using the two-flask technique described by Fattore et al. which was a variation of the technique originally described by Chalian and Barnett 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 flask. New flasks whose halves would fit the original flask were selected and placed over the original flask containing teeth and cast with wax adapted over them. Dental stone was poured into the alternate halves of the flask and invested. Following dewaxing, pigmentation was done on the teeth side of the mold cavity so that it could be transferred onto the labial surface of the final denture. The flasks were then packed with high-impact heat cure acrylic resin and cured. Both halves of the original flask now contained a processed acrylic resin shell. The two halves were fitted together to remove any acrylic resin that would interfere with complete flask 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 flask. Following trial closure, the two halves of flask were closed and cured using a long curing cycle. Once processed, the denture base was finished and polished.,
Reducing the weight of a maxillary prosthesis, however, has been shown to be beneficial when constructing an obturator for the restoration of a large maxillofacial defect. Given the extensive volume of the denture base material in prostheses provided to patients with large maxillofacial defects or severe residual ridge resorption, reduction in prosthesis weight may be achieved by making the denture base hollow.
Historically, weight reduction approaches have been achieved using a solid 3D spacer, including dental stone, cellophane-wrapped asbestos, silicone putty, or modeling clay during laboratory processing to exclude denture base material from the planned hollow cavity of the prosthesis. Multiple and separate pieces of the prosthesis are polymerized around a 3D spacer. Following the initial polymerization process, the solid spacer is removed. Individual pieces of the prosthesis are then joined using autopolymerizing acrylic resin repair techniques. Fattore et al. used a variation of a double-flask technique for obturator fabrication by adding heat-polymerizing acrylic resin over the definitive cast and processing a minimal thickness of acrylic resin around the teeth using a different drag.
Both portions of resin were then attached using heat-polymerized resin. Holt processed a shim of acrylic resin over the residual ridge and used a spacer. The resin was indexed and the second half of the denture was processed against the spacer and shim. The spacer was then removed and the two halves were luted with autopolymerized acrylic resin using the indices to facilitate positioning.
The primary disadvantage of such techniques is that the junction between the two previously polymerized portions of the denture occurs at the borders of the denture. This is a long junction with an increased risk of seepage of fluid into the denture cavity. Furthermore, this junction is a common site for postinsertion adjustment increasing the risk of leakage. A further disadvantage is that it is difficult to gauge resin thickness in the cope area. This article describes a technique for fabrication of a hollow maxillary complete denture using silicone putty to develop a cavity within the denture base.
Hollow denture using putty as spacer
Make a definitive impression of the maxillary residual ridge and fabricate the denture to the trial denture stage. Index the land area of the cast using a conical bur and seal the trial. Denture to the definitive cast. Duplicate the trial denture in reversible hydrocolloid and pour the impression in dental stone. Make a clear template of the stone cast using a 0.3-mm thermoplastic sheet. Process the trial denture in the standard manner through the wax elimination stage. Adapt two layers of baseplate wax to the definitive cast in the drag, conforming to the border extensions. Use a second flask to invest the baseplate wax and again complete the wax elimination process. Pack the cope and second drag with heat-polymerized acrylic resin and process. Separate the cope, with the polymerized acrylic resin still attached, from the drag. Place the clear matrix on the definitive cast using the indices in the land area as seating guides. Use an endodontic file with a rubber stop to measure the space between the matrix and the processed resin. Mix and adapt vinyl polysiloxane putty to the bur-roughened acrylic resin and shape to the approximate contours of the matrix. Shape the polymerized putty with a bur to leave 2–3 mm of space between the putty and matrix. Provide an additional 1-mm space over the tooth portion of the denture. Fix the putty to the acrylic resin using cyanoacrylate.
Hollow denture using salt and chocolate syrup
After dewaxing is done, then reseat the original cope on the drag and verify the complete closure of the flask. Mix, pack, and polymerize the acrylic resin. The salt crystals or the chocolate syrup is placed in the putty spacer gap created in the space. Verify adequate thickness of resin around the teeth at the packing stage using a periodontal probe. Recover the processed denture in the usual manner. Remount the denture on an articulator and adjust the occlusion as necessary. Cut two openings with a bur into the denture base distal to the most posterior teeth. Remove the silicone putty by scraping with a sharp instrument. Widen the openings as necessary, laterally, to facilitate access.
Clean and disinfect the cavity. Attach the clear resin covers by bonding them into position using autopolymerizing resin or light-polymerizing gel. Polish the denture in the usual manner. Verify that the cavity is sealed by immersing the denture in water. If no bubbles are evident, an adequate seal is confirmed.
Severe atrophy in one or both of the alveolar residual ridges of the complete denture patient presents difficult restorative problems. The advantage of a hollow mandibular denture for severely resorbed residual alveolar ridges is the reduction of excessive weight of acrylic resin which normally replaces lost alveolar ridge in the interridge space of the denture wearer.,, In order to construct a hollow-bulb denture, the customary clinical and laboratory procedures are accomplished by investing the denture in a flask. The complete lower wax denture is boiled out, and the flask is separated in the usual manner.
The hollow denture is using two split dental flasks
Place a wax shim (consisting of two layers of baseplate wax) over the denture teeth area. Place the top half of a second split flask over the wax shimmed lower half of the flask. Pour stone into the flask through the open hole. Boil out the wax shim. Pack in acrylic resin, process, and separate. Place two layers of baseplate wax over the residual ridge in the top half of the original flask. Place Insta-Mold between the wax shim and the processed acrylic resin on the residual ridge area. Notch the processed acrylic resin and the wax shim for keying when the two halves are put together later. Boil out the wax shim, pack, and process and separate the flask. Remove the Insta-Mold.
After completion of the try-in appointment, invest and dewax the maxillary waxed trial denture in the usual manner. Adapt two sheets of modeling wax on the definitive cast in the base of flask. Each sheet of modeling wax measures approximately 1.5 mm thick. Make three cylinders using autopolymerizing resin, measuring 2 mm in diameter and 5 mm in length.
Make three retentive grooves, one on the intaglio surface of the left central incisor and one on each of the first molars. Attach the autopolymerizing resin cylinders into the retentive groove using cyanoacrylate resin. The cylinders must be positioned perpendicular to the teeth, along the path of closure of the flask. They are meant to function as stoppers for the 3D spacer. Adapt two layers of modeling wax on the labial, palatal, and acrylic binding surfaces of the teeth to mimic the final uniform thickness of the acrylic resin. This will result in the stoppers being exposed by 2 mm. Confirm the exposure of the stoppers by using a periodontal probe.
Verify accurate flask closure. Mix and adapt condensation silicone putty into the space available and close the flask. Maintain the clamp pressure until the putty polymerizes. Open the flask, remove the putty, and trim the excess wherever required. Verify the accurate fit of the putty spacer. Reassemble the flask to verify accurate flask closure with the spacer in place. Coat the 3D putty spacer with a thin, uniform layer of petroleum jelly and embed it in freshly mixed condensation silicone putty and light-body material (Zetaplus) up to the upper border of the 3D putty spacer and allow it to polymerize to get an index.
Ensure the complete flow of light-body material into the indentations of the spacer, to mimic the autopolymerizing resin stopper. Dewax the flask to remove the wax adapted while making the 3D putty spacer and apply separating media. Heat sugar in a stainless-steel bowl on an open flame at a temperature between 180°C and 250°C and stir intermittently to prepare the caramel, pour the liquid caramel into the putty index, and allow it to cool. Remove the caramel spacer and verify its fit on the autopolymerizing acrylic stoppers in the flask. Mix heat-polymerizing acrylic resin, pack the flask, and carry out a trial closure ensuring orientation of the putty spacer according to the stoppers. Open the flask and verify that 2 mm of the acrylic stopper is exposed. Using a periodontal probe (Williams probe), confirm that a uniform thickness of heat-polymerizing resin has been achieved on the labial and palatal surfaces of the definitive cast. Replace the 3D putty spacer with the 3D caramel spacer and close the flask. Polymerize the denture and recover the processed denture in the usual manner. Make two small openings, each measuring 3 mm in diameter distal to the most distal tooth, and keep the denture in water overnight. Disinfect, air-dry the cavity, and seal the openings using autopolymerizing resin. Polish the denture in the usual manner. Verify the integrity of the seal after polishing by immersing it in water.
Complete the clinical try-in procedure of waxed up trial denture. Invest and dewax the maxillary denture in the conventional manner. Use the double-flask technique, to fabricate a heat polymerized maxillary denture base on the definitive maxillary cast. During deflasking, do not separate the denture base from the cast. Make indentations of approximately 0.5–1 mm in depth and 5 mm in width on the processed denture base with acrylic burs in the premolar and molar region. On both sides for orientation of the 3D spacer, making sure that the denture base is not perforated. Adaption was done with two layers of 1.2-mm-thick wax sheet onto the labial, palatal, and acrylic binding surfaces of the teeth present in the plaster mold embedded in the cope.
Make sure that the wax is closely and uniformly adapted to the surfaces as it models the thickness of the resin that will be obtained after processing, and also provides an outline for the putty index. Manipulate vinyl polysiloxane putty, according to manufacturer's instructions, mold it into a U-shape, and place it over the wax adapted on the teeth. Carefully close the flask, ensuring rim-to-rim contact throughout. Open the flask after the putty is set and trim the excess. There must be no evident gap between the cope and drag. Once verified, the putty index is used to make the 3D spacer.
To obtain a 3D printed spacer, first, scan the index using a 3D scanner to generate a digital (STL) file. Upload the STL file into computer-aided design software. Set design parameter of 1.25-mm wall thickness to create a hollow space within the solid STL file (this uniform wall thickness provides sufficient spacer material to prevent fracture during flasking). Utilize this modified file to print a 3D hollow spacer with dental SG resin. Autoclave the 3D printed hollow spacer. Orient it on the previously fabricated denture base. This is made possible by utilizing the orientation indentations created at the premolar and molar region on both sides of the denture base. Verify the placement by checking for stability and adaptation to the denture base.
Remove the wax adapted in the cope, then secure it in place using cyanoacrylate resin. Apply two thin layers of separating medium on all gypsum surfaces in the cope and drag. Avoid applying on the acrylic surface of the teeth and on the processed denture base. Mix and pack heat cure acrylic resin following manufacturer's instructions. Ensure uniform closure of the flask parts to prevent any increase in vertical dimension after processing. Process the denture by following conventional polymerization cycle. After deflasking, finish and polish the prosthesis.
The resin spacer remains within the denture flask technique is technique-sensitive as the two flasks may not fit accurately which leads to an inadvertent increase in vertical dimension. Furthermore, the junction of the two parts of the denture may fracture, discolor, or leak with time. 3D printed spacer attached to denture base using cyanoacrylate. In single-flask techniques, the various materials used for creating a 3D space require retrieval after denture fabrication to create a hollow space. The retrieval of some materials used in the past has proved difficult, particularly from the anterior part of denture.
The benefit of using this technique is ease of handling the 3D spacer as it is solid and fixed to the denture base and retrieval is not required unlike other materials described previously. Furthermore, there is no discoloration, as seen in the double-flask technique. They include cost and availability of 3D scanner, 3D printer, and dental SG resin material. The required thickness of dental SG resin limits the volume of space that can be created within the prosthesis. This technique is a modification of the conventional double-flask technique; two flask assemblies were used to obtain the processed denture base. However, the rest of the procedure was completed using a single flask. The processed denture base on the definitive maxillary cast (drag) with the printed spacer and the teeth containing portion (cope) were flasked together as a single unit. Therefore, the resulting denture was a single processed unit instead of two parts, as would result from a standard double-flask technique. This helps to overcome the occurrence of a vulnerable junction prone to discoloration, breakage, or leakage. In this technique, two layers of base plate wax were adapted onto the teeth contained in the cope.
The vinyl polysiloxane used to fabricate the 3D spacer does not bond to the acrylic, so removal of the spacer index is easy. The printed spacer is made of resin and chemically adheres to the denture base. It is to be retained within the denture without having to prepare any holes for the purpose of retrieval. It can be autoclaved and is biocompatible, the spacer to remain within the denture posing no harm to the wearer. Care was taken while placing the orientation indentation to encroach only up to partial thickness of the denture base without any perforation. This prevents any direct contact with the spacer. The robust structure enables the resin spacer to withstand the forces of compression applied during flasking.
The 3D printed spacer can also be used in the construction of hollow large-sized obturators to obtain the same benefits. The difference in weight was measured by duplicating the denture with the same tooth mold and material without a hollow space. The weight of the hollow denture was 27.77 g and the duplicated denture was 31.80 g, a 4-g reduction in weight. The lighter weight prosthesis may be more comfortable to wear and may reduce the forces acting on the residual alveolar ridge, preserving the health of the underlying tissue. Research is necessary concerning other materials that can be 3D printed and are able to resist fracture in reduced dimensions than that of dental SG resin.
| Discussion|| |
The oral health is not different from general health. As age increases, biological phenomena are adversely affected in association with escalating and irreversible deterioration of functional capacities of various organs and tissues. Aging is a natural phenomenon whereas elderly individuals will tend to exhibit inexorable transformation., The physiological changes occur both in extraorally and intraorally such as skin, mucosal layer, bone, salivary secretion, jaw movements, taste, and nutritional status.
Edentulism is the endpoint of chronic oral diseases in elderly people. The incidence of total tooth loss has decreased in high-income countries in recent decades. In spite of these reductions, an age and social gradient exists, with prevalence being highest in the elderly as well as in socioeconomically weak groups. Hence, edentulism is likely to remain a significant health condition requiring rehabilitation.
In edentulous patient the vertical displacement of mandible shortens and the chewing cycle tends to become slow, due to lack of muscle activity and tone. Complete dentures are the most common restorative treatment for edentulism, which satisfy the basic principles of retention, stability, and support. Although the dental literature reports a declining prevalence of this condition in some developed countries, there are still a large number of subjects needing prosthodontic treatment worldwide., Even though the conventional complete denture is considered gold standard prosthodontic therapy for edentulous individuals, it cannot reserve in all edentulous conditions due to regressive or degenerative changes in supporting tissues and neuromuscular control militate against a continuum of an adaptive functional and esthetic appearance and also in individuals who possess some compromised conditions such as severely atrophic ridges, flabby or hyperplasic mobile soft tissue, xerostomia, microstomia, labially inclined premaxilla, hypermobility of tongue, macroglossia, cleft lip, and scleroderma.
Basically, the role of prosthodontist is not only the replacement of teeth and also replacement of missing facial support due to various causes such as early tooth loss, alveolar resorption, reduced tonicity of muscles and sunken cheeks. In such compromised edentulous condition where the treatment option with conventional complete denture creates major discomfort as the residual ridges are unable to tolerate the weight of denture due to severe resorption, increase in interocclusal distance, increased mechanical irritation due to improper fit of dentures, and increased muscle activity.,
To overcome all these drawbacks of conventional complete dentures, the hollow dentures were brought into field which would enhance the basic principles such as retention, stability, and support in compromised condition, especially in patients with highly resorbed ridges. The fabrication steps follows the same as that of the conventional complete denture using compression molding technique but the quantity of PMMA required is comparably less in amount and also the spacer material is incorporated during packing that creates the hollow space in the final prosthesis which is the difference exists compared to the conventional complete denture. Hence, it had been proved that it reduces 25% of the total weight of the denture in the present as well as the previous literature.,,
Meenakshi et al. conducted a study with conventional dentures and overlay dentures to compare their abilities to discriminate between occlusal forces. They concluded that all subjects with over dentures regained the sensory values similar to those reported for natural teeth. Michael CG and Barsoum WM compared the three surgical techniques of simple tooth extraction, labial plate, and interseptal alveoloplasty. They concluded that simple tooth extraction is the best approach that can be followed to preserve the alveolar ridges.
Daniel et al. Mor D investigated the denture stability and retention was retained roots of the teeth. They concluded that these teeth aid in denture stability and retention. Holt RA Jr explained the technique that decreased the weight of heavy lower denture by 25% were weight, may be a contributing factor to the superior resolution of a patient's problem with hollow denture. Fattore LD described the double-flask technique for the fabrication of the hollow bulb portion of a maxillary obturator in atrophic maxillary alveolar condition with increased interocclusal distance. Radke U and Mundhe D introduced a simple technique of fabricating a hollow maxillary complete denture in a patient with resorbed maxillary and mandibular ridges with increased interridge distance which reduces the weight of the prosthesis.
Mor et al. introduced the method for edentulous patients in rehabilitation of both maxilla and mandible at the resorbed condition where there are increased interridge distance outcomes resulting in the fabrication of the hollow dentures. Bhochhibhoya et al. suggested a new technique for fabrication of ill-fitting maxillary removable partial dentures. They fabricated hollow dentures using altered cast impression technique in which the palatal portion of removable partial denture was made of thermocol. The authors concluded that it was a novel method of hollowing with several benefits, which includes minimal chairside time, treatment cost and enhanced patient satisfaction.
Deogade et al. suggested a technique for making a hollow denture. The authors found difficulty in retrieval of materials and the seepage of fluid with this technique, thereby making a small opening in denture teeth. Thus, the authors concluded that it was an alternative approach for hollowing maxillary denture in which gelatin was used as spacer. Qanungo et al. ssuggested a technique for fabrication of hollow denture using glycerin soap as space,r which is easy to carve and retrieve. It does not adhere to the acrylic resin. They concluded that it is also a simple, economical, time-saving technique and the light dentures are fabricated that provide adequate retention and decrease the leverage in resorbed condition.
D'souza and Aras described a technique for the fabrication of hollow denture with a 3D spacer. They incorporated that the salt can be used as the spacer that reduces the resorption. The authors concluded that it is a new innovative technique that results in less weight dentures that aid in better retention and comfort in case of severely resorbed ridges. Bhushan et al. described an innovative technique for fabrication of hollow denture using single-flask technique with caramel as spacer material. Shah et al. described the innovative technique for the fabrication of hollow maxillary complete denture using 3D printed template in which the double-flask technique was used and modifier with the hollow spacer during the time of closure. All this literature review provides the similar results that there is a 25% reduction in the weight of the final dental prosthesis. The clinical implication of this hollow dentures is where the interocclusal distance is more when compared to patients with the ideal ridge, which prevents further resorption, muscle fatigue and atrophy of muscles.
| Conclusion|| |
There are increased retention, stability, and comfort in condition of highly resorbed ridge with increased interocclusal distance that also prevents the muscle atrophy and fatigue in elderly individuals.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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